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COLORADO DIVISION OF WATERRESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., Sle 821, DENVER CO 80203 <br />Phone: (303,)866-3581 Fax 303 888-2223 dwirziermitsorillneilbstate.coms <br />Office Use Only Foml CiHIS --+t66 (11/2011)' <br />MONITORING /OBSERVATION <br />Water Well Permit Application <br />Review Instructions on reverse aide prior to completing form. <br />The form must be typed, completed online or In black or blue Ilk. <br />1. Wall Ownir Information <br />"a of well amof <br />Colowyo Coal Company L.P. <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />and/or water quality sampling <br />Moffiry sees <br />5731 State Highway 13 <br />7. Well Data (proposed) <br />CRY <br />Meeker <br />State <br />CO <br />Zip code <br />81641 <br />p <br />841 feet <br />a. Consultant Information (if applicable) <br />Telephone # <br />970 -824 -1200 1 <br />E rig online it Is ramrod) <br />Name of carried Person <br />2. Type Of Application (check applicable bones) <br />■ Use existing well I] Replacement for existing monitoring well: <br />❑ Constnxd new well Permit no.: <br />O Other. MH 45636 <br />Company name <br />Melling address <br />3. Rafer To (if applicable) <br />MonitoringhosacknovAKOviant <br />MH- 45636 <br />Wdlnamor# <br />C -05-33 <br />City <br />State <br />Zip /ode <br />4. Location OIF P - ttd Well Im oitantl See Instructions), <br />Teiap,«ra # <br />Moffat <br />NW 1/4ofthe SW 1/4 <br />- Llt�itnse � onal <br />9. P ed WeII Drilier ":" " <br />sedon <br />11 <br />Taywiship <br />3 <br />I Nor 87 <br />r r <br />;94 <br />Flange <br />orw <br />r Pr <br />Prindpaimerhtion <br />10. Name of Well Owner or Authorized Agent <br />The malting of- false slat manWhar�rroaiatihitas pe►�ly l tlw second <br />dogma, which is punishable as a doss 1 misdemeanor pursuant to C.R.S. <br />24 -4-104 (13xa� I Have read the statements herein, know the contents <br />thereof and state that they are true to M knowledge. <br />Distance of Men tram section roes (section rhea are typically not property ones) <br />1400 Ft from) —, N rx— S 900 i:t from 1 E KJ W <br />Sir or enter till nsms here <br />Dama ( ) <br />((h h� <br />For aanwHwN y— an from old wall to row viall <br />feet direction <br />prhttne iinie� �othwtiers -oas�f <br />&art -+p t4 , � o l <br />l <br />Well location address (Include City. Statd Zip) Check n win adtess is same as Man 1. <br />Office a Isilly <br />Optional: GPS wat location information in UTM format <br />You must check GPS unit for required settings as follows: <br />US= map norm <br />OW map nor <br />StuTaCe stay. <br />Format rrust be Ural <br />Ill zone 12 or r zone 13 <br />Units moat be Meters <br />Dalian rust be WAD83 <br />Unit nest be set to true north <br />Was GPS unit choclod for obwe? I] YES <br />Easting <br />Northing <br />PAmember to tat Datum to NAD83 <br />Receipt area only <br />S. Property Owner Information <br />Nomeofpfowwownw <br />Colowyo Coal Company L.P. <br />Mailing address <br />5731 State Highway 13 <br />DIV WD- BA _ MD _ <br />qty <br />Meeker <br />Stale <br />CO <br />ap Code <br />81641 <br />Telephone # <br />970 -824 -1200 <br />