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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />Office Use Only Form GWS46 (11/2011) <br />1313 SHERMAN ST., Ste 821, DENVER CO 80203 <br />Phone: 303 866 -3581 Fax: 303 866 -2223 dwr ermitsonline state.co.us <br />MONITORING /OBSERVATION <br />Water Well Permit Application <br />Review instructions on reverse side prior to completing form. <br />The form must be typed, completed online or in black or blue ink. <br />1. Well Owner Information <br />Name of well owner <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />Bestway Concrete & Aggregate <br />and /or water quality sampling <br />Mailing address <br />301 Centennial Drive <br />7. Well Data (proposed) <br />Total depth <br />Aquifer <br />City <br />Slate <br />Zip code <br />Milliken <br />CO <br />80543 <br />16 feet <br />alluvial (St. vrain) <br />8. Consultant Information (if applicable) <br />Telephone# <br />E-Mail (if filing online it is required) <br />Name of contact person <br />970 356 7523 <br />markjohnson @bestwayconcreil <br />2. Type Of Application (check applicable boxes) <br />❑ Use existing well El Replacement for existing monitoring well: <br />Company name <br />❑ Construct new well Permit no.: <br />N Other: monitoring well <br />Mailing address <br />3. Refer To (if applicable) <br />Monitoring hole acknowledgment <br />Well name or # <br />City <br />State <br />Zip Code <br />MH- 52223 <br />NW <br />4. Location Of Proposed Well Important! See InstructionsL <br />Telephone# <br />County <br />Weld <br />NE 1 /4ofthe NW 1/4 <br />9. Proposed Well Driller License #(o tional): <br />Section <br />Township <br />N or S <br />Range <br />E or W <br />Principal Meridian <br />10. Name of Well Owner or Authorized Agent <br />1 <br />2 <br />I <br />FX t <br />68 <br />r x <br />6th <br />The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br />24-4 -104 (13)(a). I have read the statements herein, know the contents <br />Distance of well from section lines (section lines are typically not property lines) <br />thereof and state that they are true to my knowledge. <br />_ <br />151 Ft. from (x N F S 1450 Ft. from E X W <br />Sign or enter full name here <br />Date (mm/dd /yyyy) <br />For replacement wells only — distance and direction from old well to new well <br />feet direction <br />If signing print name. Print title if other than land owner. <br />Well location address (Include City, State, Zip) ❑ Check if well address is same as Item 1. <br />Office Use Only <br />Optional: GPS well location information in UTM format <br />USGS map name <br />DWR map no. <br />Surface elev. <br />You must check GPS unit for required settings as follows: <br />Format must be UTM <br />(-- Zone 12 or f Zone 13 <br />Easting <br />Receipt area only <br />Units must be Meters <br />Datum must be NAD83 <br />Northing <br />Unit must be set to true north <br />Was GPS unit checked for above? ❑ YES <br />Remember to set Datum to NAD83 <br />5. Property Owner Information <br />Name of property owner <br />Bestway Concrete & Aggregate <br />Mailing address <br />301 Centennial Drive <br />City <br />State <br />Zip Code <br />Milliken <br />CO <br />80543 <br />Telephone # <br />DIV WD BA MD <br />970 356 7523 <br />