Tamarack Contract and Supporting Docs

• Description: Tamarack Contract and Supporting Docs
• State: CO
• State: NE
• Basin: South Platte
• Water Division: 1
• Date: 11/18/1999
• Title: Tamarack Contract and Supporting Docs
• Water Supply Pro - Doc Type: Contract/Agreement

CO ORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 818, DENVER, CO 80203
phone - info [phone] main [phone]
fax [phone] http 11www water slate co us
MONITORING /OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form
The form must be completed in black ink
1 W ell Owner Informat
Name of well owner
�G`Or c'c`v Q tV S �v► �� l V �d�\ l '�
C.oL\.�ca.�
elty -__ - -- - - -- -- -- - Slate i Zip code
I
., —+.�.. • vim • � — L V L \ 1p
Telephonep
( -S 3 ) ? �t 'i \ q 2
2 T yp e Of A ppl ica tion ( che c k ap boxe _
Use existing well ❑ Replacement for existing monitoring well
❑ Construct new well Permit no
❑ Other i
3 Refe To ( if applicab
Monitoring hole acknowledgment well name or fr
MH 'SAC �-1 ( �`T - 13
4 Location Of Proposed Wel
County 11 """���IIIIfff
F..VC,C�n i C�- - 114 of the C 114
Section J T Township Nor $� Renga E or W Pnnc pal Met d an
13 i1 0 so lL4cl 0"1" 1 4)
L 5r, C Ft from ❑ N ® S G_7 QD Ft from ® E ❑ W
iZ wells only - dlstence and direction from old well to new well
feet_ _ _ direction
Well location address (if applicable)
Optional GPS well location Information In UTM format
Required settings for GPS units are as follows
Formal must be UTM ------- - -~ -_- - �- - - - - -
se
Form GWS-46 (1/2001)
Zone must be13 I Northing _
I ----------------- --- - °-
Units must be Meters
Datum must be NAD27 (CONUS)
Unit must be set to true north Easting
Were points averaged? ❑ YES ❑ NO i
5 Property Owner Information
Name of property owner
� r
Cti10 dc, C3 k Q 5
Melling address
City Slate Zip
1�,2 nVS� l o
Telephone N -
(303) Zy IIyZ
6 Use Of Well_
Use of this well is limited to monitoring water levels
and/or water quality sampling
7 Well Data (proposed)
Total depth Aquila,
I`:i feet 1 4 1-111)1 -LA
8 Censuitant Information (if appitr_.ahle)
Name of contact person
Company name
Mailing address
City State Zip Code
Telephone p
9 Proposed Well Driller License optional
10 Signature Of Well Owner, Consultant Or Authorized
_ Agent
The making of false statements herein constitutes perjury In the second
degree which is punishable as a class 1 misdemeanor pursuant to C R S
- 4 1 04 (13)(a) i ha recad the Statements herein know the contents.
thereof and state that they are true to my knowledge
Sign h to (Must be orfgl f signalu _\ - I Dete
X\ � t��C�a �` 3 `2v (o I
Pont name & title
M a. %_-) Q 1-\C.\ c5\ a, � Crz .+roc c?1�� ra�51
Office Use Only
USGS map name _J DWR map no { T { Surface elev
I 1
Receipt area
DIV --_ -- WD ----- BA -__- MD -_ --