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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />Office Use Only Form GWS-46 (1112011) <br />1313 SHERMAN ST., Ste 821, DENVER CO 80203 <br />Phone: (303) 866-3581 Fax: (303) 866-2223 dwrpermitsonline@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 />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 />1,500 feet 1 <br />WOLF CREEK COAL/013 <br />Telephone # <br />E-Mail (If filing ortine it is required) <br />8. Consultant Information (if applicable) <br />970.870.2712 Tjneftleton@peabodyenergy.COM <br />it <br />Name of contact person <br />KEITH THOMPSON <br />2. Type Of Application (check applicable boxes) <br />C3 Use eAsting well 9 Replacement for e)dsting monitoring well: <br />0 Construct new well Permit no.: <br />El Other: <br />Company name <br />TETRATECH <br />Mailing address <br />3801 AUTOMATION WAY <br />3. Refer To (if applicable) <br />Monitoring hole acknowledgment <br />w <br />Well na me or# <br />city <br />State <br />Zip Code <br />MH- T14-013AWC <br />_0 <br />FORT COLLINS <br />CO <br />80525 <br />4. Location Of Proposed 11 (important! See I <br />Telephone # <br />970.206.4202 <br />County <br />Routt <br />NE 1/4 of the SW 114 <br />9. Proposed Well Driller License #(optional): <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 />17 <br />5 <br />r)—c 17, <br />1 <br />86 <br />F FX <br />I <br />6TH <br />I <br />The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a class I misdemeanor pursuant to C.R.S. <br />24-4-104 (13)(a). I have read the statements herein, know the contents <br />thereof and state tha_Wey are true to my knowledge. <br />Distance of well from section lines (section lines are typically not property lines) <br />Ft. fromr— N fx— S Ft. from 1, 1 t jj�l VV <br />2,500 1,600 <br />Aa re <br />Sign or enter fo rye <br />Date (mrricid") <br />For replacement wells only - distance and direction from old well to new wel <br />150 feet West direction <br />if signing print na�;WPnt the if other than land owner. <br />well locaton address (include City, State, Zip) 0 Check ifwell address is same as Item 1. <br />Office Use Only <br />Optional: GPS well location information in UTM format <br />You must check GPS unit for required settings as follows: <br />USGS map name <br />surface We, <br />Format must be UTM <br />f— 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 rrvust be set to true north <br />Was GPS unit checked for above? 0 YES <br />Remember to set Datum to NAD83 <br />5. 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 />SAME AS ABOVE <br />DIV WD BA IMD <br />�r <br />