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COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only Form GWS-46 (11/2011) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., Ste 821, DENVER CO 80203 <br />Phone: (303) 866-3581 Fax: (303) 866-2223 dwrgermitsonlinepstate.co.us <br />MON ITORI NG/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 />TWENTYMILE COAL, LLC <br />and/or water quality sampling <br />Mailing address <br />29515 RCR27 <br />7. Well Data (proposed) <br />city <br />state <br />Zip code <br />Total depth <br />Aquifer <br />OAK CREEK <br />CO <br />80467 <br />860 feet <br />WOLF CREEK COAL/013 <br />8. Consultant Information (if applicable) <br />Telephone # <br />E-Mail (If filing online it is requi <br />Name of contact person <br />KEITH THOMPSON <br />970.870.2712 lineftleton@peabodyenergy.COM <br />2. Type Of Application (check applicable boxes) <br />❑ Use existing well ❑ Replacement for existing monitoring well: <br />Company name <br />0 Construct new well <br />TETRATECH <br />Permit no.: <br />Mailing address <br />❑ Other: <br />3801 AUTOMATION WAY <br />3. Refer To (if applicable) <br />Monitoring hole acknowledgment <br />Well name or# <br />vv"" <br />city <br />State <br />Zip Code <br />MH- <br />T14-01218WC <br />FORT COLLINS <br />CO 180525 <br />4. Location Of Proposed Well (Important! See Instructions) <br />Telephone # <br />970.206.4202 <br />County <br />Routt <br />NE 114 of the SE 1/4 <br />9. Proposed Well Driller License #(ciptional): <br />Section <br />Township <br />IN or S <br />Range <br />E or W <br />Principal Meridian <br />10. Name of Well Owner or Authorized Agent <br />Fx- r- <br />I <br />r- rx <br />The making of false statements herein constitutes perjury in the second <br />14 <br />5 <br />86 <br />6TH <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 />- <br />Distance of well from section lines (section lines are typically not property lines) <br />thereof and state-t are true tom knowledge. <br />2,350 Ft. fromr— N FX­` S 100 Ft. from Ix L I VV <br />Sign or enter brns he <br />Date (mrriddlyyyy) <br />For replacement wells orgy – distance and direction from old well to new well <br />feet direction <br />if—signing name. I 'us her. than land owner. <br />Well location address (include City, State, Zip) E 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 />77ap no. <br />Surface elev. <br />You must check GPS unit for required settings as follows: <br />Format must be UTM <br />Ej– Zone 12 or r 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 />Remember to set Datum to NAD83 <br />Was GPS unit checked for above? ❑ YES <br />I <br />6. Property Owner Information <br />Name of property owner <br />TWENTYMILE COAL, LLC <br />Mailing address <br />SAME AS ABOVE <br />City <br />state <br />Zip Code <br />Telephone # <br />DIV_ WD_ BA_MD_ <br />SAME AS ABOVE <br />ems <br />