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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />Ofte Use Only Form GWS46 (1112011) <br />_ <br />1313 SHERMAN ST., 8% $21, DENVER CO 50203 <br />Phone: 303 866 -3581 Fax 303 855-2223 s <br />MONITORINGIOBSERVATION <br />Water Well Permit Application <br />Review Instructions on reverse side prior to competing form. <br />The form must be typed. completed online or in black or blue Ink. <br />1. Well Owner Information <br />Name orwdl owner <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />Colowyo Coal Company L.P. <br />and/or water quality sampling <br />mono auarew <br />5731 State Highway 13 <br />7. Well Data (proposed) <br />CRY <br />state <br />p coft <br />fP <br />Meeker <br />CO <br />81641 <br />515 feet <br />8. Consultant Infornation (if <br />applicable) <br />TOWN" <br />E- tAe11 (x cup mono Its regdred) <br />Nana of corded pason <br />970 - 824 -1200 <br />2 Type Of Application (check applicable boxes) <br />■ Use existing well D Replacement for existing monitoring well: <br />Cwroany nano <br />❑ Construct new well Permit no.: <br />O Other MH 45635 <br />WlIng address <br />3. Refer To (if applicable) <br />Well name or <br />Oily <br />state <br />zip code <br />MH- 45635 <br />ST -06-04 <br />4. Location Of Proposed Well <br />tm 6dantl See Inatrtilotialiis . <br />r "°ph a <br />ccwmy <br />Moffat <br />SE 1m of me NE 114 <br />9.Progdeed Well DrI1Ar L.i=ttd nal - <br />on <br />Tomwilp <br />or <br />EorW <br />Pdndpai en <br />10. Nara of Well Owner or Authorized Agent <br />19 <br />3 <br />r r <br />93 <br />r' <br />The rhaking of false steternsnts herein constitutes ry the second <br />degree, which is punishable as a clans 1 misdemeanor pruauant to C.R.S. <br />24-4 -104 (13xa). 1 have read titer etWamenta herein, know the comer to <br />thereof and state that are true to my knowledge. <br />Distance dwell man aeeNon tines (section knee are eypkaNy rat property Ikres) <br />2000 Ft. nanlx: N r S 689 FL rrom la' E f7 W <br />or avor name bare <br />mss <br />�� 11 <br />only — dslimce and diroclim ftm old wall to new well <br />feet direction <br />s g price name 11 ' other sron (r. <br />�a `� <br />well location address (include City, State, Zip) Check r wait addreaa is same as Nair 1. <br />Office Use Only <br />Optional: GPS well location Information In UTM format <br />USM amp name <br />ON map no. <br />stgrace . <br />You must check GPS ure for required settings as fellows: <br />Fomat must be UTM <br />1- Zone 12 or r'. Zone 13 <br />Easting <br />Receipt area only <br />Units must be Maters <br />Datum mast be NAD83 <br />Northing <br />Unit rest be set to We north <br />Was GPs unit drecked for above? ❑ YES <br />Remernber to met Datum to NA083 <br />5. Property Owner Information <br />Name of pmp" owner <br />Colowyo Coal Company L.P. <br />Malting address <br />5731 State Highway 13 <br />qy <br />Slale <br />Zip Code <br />Meeker <br />CO <br />81641 <br />Telephas a <br />DIV i WD_ BA- MD _ <br />970 -824 -1200 <br />