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DECOLORADO DIVISION OF WATER PARTMENT OF NATURAL RESOURCES <br />Use Only Form GWS-46 (11/2011) <br />1313 SHERMAN ST., Ste 921, DENVER CO 80203 <br />Phone: 303 886 -3581 Fax: (303) 8982223 <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 w'eg &Misr <br />6. Use of Well <br />Use of this well Is limited to monitoring water levels <br />Axial Basin Coal Company <br />and /or water quality sampling <br />KUMV address <br />5731 State Highway 13 <br />7. Well Data (proposed) <br />pry <br />state, <br />Zlp Coda <br />TCW ftpth Muller <br />Meeker <br />CO <br />81641 <br />497 feet <br />8. Consultant Information (If applicable) <br />moons <br />.Ma na na s reoreM <br />970 - 824 -1200 <br />2. Type Of Application (check applicable boxes) <br />E Use existing well O Replacement for existing monitoring well: <br />company name <br />O Construct new well Permit no.: <br />O Other. MH 45885 <br />Mallingaddress <br />3. Refer To (if applicable) <br />11010~14hol6admooledwrtard <br />name or <br />Gty <br />Slate <br />ZIP Code <br />MH- 45885 <br />C-06-34 <br />4k-Location Of-Proposed Well OmportaW We Int wOons <br />T"ep1i � <br />County <br />Maffat <br />SE im of the SE 114 <br />9. Proposed Well Driller License 0(optionall. <br />section <br />ownstdp <br />NorS <br />fftn ile <br />EorW <br />ftindpalkWdan <br />10. Name of Well Owner or Authorized Agent <br />1 <br />3 <br />r r <br />94 <br />F- Ix <br />The making of = statements rain cat peryury In the second <br />degree, which is punishable as a class 1 mledemeanor pursuant to C.R.S. <br />24 -4-104 (13xa� I have read the statements herein, know the contents <br />thereof and state that are true to m. <br />Distance of well from section Mee (aecaon Ilrres are typkary not property lines) <br />670 F. rf °Ar N K ' S 1030 Fl, ftm Ill E r w <br />n or name Hare <br />Date (Mrokld"yy) <br />t� Ii <br />For reptaosmen s y- distance aW OnMon ftndTd%QMneW we <br />feet direction <br />gn n��/ s <br />e • � r a <br />t or UZG� <br />Wes loeatldn address (include Cky, Stag. Zip) Check K well address Is sane as Item 1. <br />Office Use Only <br />Optional: GPS well location Infonnetlon in UTM fomsat <br />USGS map name <br />0WRmspno. <br />surlece dev. <br />You must check GPS unit for required settings as follows: <br />Format must be UTM <br />F Zone 12 or f- Zone 13 <br />Easting <br />Receipt area only <br />this must be Meters <br />Debars moat be NADe3 <br />Northing <br />Unit must be set to true north <br />Was GPS unit checked for above? O YES <br />Remember to set Datum to NAD83 <br />5. Property Owner Information <br />pn>ae"r awe► <br />Axial Basin Coal Company <br />Melling address <br />5731 State Highway 13 <br />city <br />State <br />Zip Code <br />Meeker <br />CO 181641 <br />Telephone # <br />DIV _ WD_ BA _ MD _ <br />970 - 824-1200 <br />