Laserfiche WebLink
COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., Ste 821, DENVER CO 80203 <br />Ptlone: 303 866-3581 Fa1c 303 866-2223dwr irrutsonlult �agstate Gi.:1ti <br />Office Use Only Fn (3WS-46(11/2011) <br />MONITORINGIOBSERVATION <br />Water Well Permit Application <br />Review insbuctions on reverse side prior to completing form. <br />The form must be typed, completed online or in !Nock or blue ink. <br />1. Well Owner information <br />Nam of will Omer <br />Y FUELS C_0 Ft L, l\ic <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />and/or water quality sampling <br />M"g address <br />rO Br'x 4-99 <br />7. Well Data (proposed) <br />Tor'! d"* 6 <br />� ']� feet <br />er D A f2RZv�r <br /><<)A L :,) EA M <br />cey <br />r Lc;f 2E�JCi` <br />Sate <br />Cc <br />zip code <br />ries l -2'2(o <br />8. Consultant Information (If applicable) <br />1eiephow s <br />719 7F? Y (e 3 q 5 <br />E-rMal (r &Moft d K reamed) <br />efc%)a l kD dna+ I d CO m <br />Nam of coraw pear <br />C-ECRGr- V, F'ON i l E:R--)0 ►a <br />2. Type Of Application (check applicable boxes) <br />❑ Use existing well ( Replamnent for ex iMM monitoring well: <br />• Constrixx Permit no.: new well 2 g c f 785 <br />O Other: <br />c4nipowOarm # <br />(5/;v- ! E A S —rEM / <br />Mwq address <br />3. Refer To (d applicable) <br />Ma daft hole a d, '01 <br />MH- <br />Wei name or s <br />MW - N W <br />CM <br />Sue <br />�� <br />Telepnare ` <br />4. Location Of ProWell <br />(Importantl See Instructions <br />count <br />j-Vf-fV\ NIT <br />SW SSV 'N <br />9. Proposed Well Driller License tional : 592 <br />10. Name of Well Owner or Authorized Agent <br />Section <br />t ` 1 <br />Townhq) <br />2 Ci <br />I N or S <br />x <br />Rage <br />�j� <br />I E or W <br />)C <br />I PrrnapY Maidan <br />! TN <br />lO <br />The malting of false herein conedbles perpry in the second <br />ftgm, wtkh is pifflieligbia as a doss 1 misdemeanor prrsuari to C.R.S. <br />24-4-104 (13xa). I have read the staldnenla herein, know the conimits <br />thereof and stats that Um are true t0 my knoWedge. <br />Datance of wag ran section lance (secenn bras are typcaNy not popery Wee) <br />1 10 Ft. ran N x S 45 Ft. ran E X W <br />1roplaosnerd <br />-9;;—or ems r. corm nae <br />t 1 ✓CGL "" - <br />LL <br />Dab (mmVd0*M <br />�Jr / /-dam 1 <br />Far weft any - aetrrce and deecOm from old w9N to new will <br />Q -� <br />2 Cio• = feet S S W direction <br />it _�pire P1riM Wk d a m *w laid amm (� <br />C�'wemRC••� VI <br />Wei tacaiiar address (Wic We CAV. Stale. Zip) 0mck d %a address a sane as Nan 1. <br />Office Use Only <br />Optbnal: GPS well location rdormatim m UTM format <br />You must check GPS crit for regtred setOngs as follows: <br />USGS mop name <br />OM mep no. <br />Surber elev. <br />Former mast be UTM <br />zone 12 or)(Zom 13 <br />units must be Meters <br />0a4%M must be Nnosa <br />Urvt must be ser b true north <br />Was GPS rad checked for above? ❑ YES <br />Eas" f�a 3 <br />�L <br />NOMmg .2 Z•5 / 7 <br />Rensena fr to set Dahm to NAD93 <br />Receipt area only <br />5. Property Owner information <br />Nmm of prop" awns t= hl l C� A M i l._. y <br />D Ll V fl A q A u Nt7Cr'S <br />Ma" address <br />3+205 5 FCRE,5-T i'ARI- <br />DIV WO_ BA_ MD _ <br />Cry <br />EUBk1kCiF-TN <br />State <br />I co <br />rs Code <br />7 <br />Telephones <br />-3 �,,j �/ <br />C� .J � ('6 f 7� <br />