2015-08-11_PERMIT FILE - C1992080 ‎(2)‎

• Permit No: C1992080
• IBM Index Class Name: Permit File
• Doc Date: 8/11/2015
• Doc Name: Well Information Abridged Permit
• Section_Exhibit Name: Appendix 5-13
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES
Office Use Only Form GWS as (7/2012)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER, CO 80203
Main: [phone] Fax: [phone] d ermitsonline state.co.us
RESIDENTIALNote: Also use this form to apply for livestock watering
Water Well Permit Application
Review form instructions prior to completing form.
Hand completed forms must be completed in black or blue ink or typed.
1. Applicant Information
Names) .. -. -. - .... __....._----___--- _ _ _.__
6. Use Of Well (check applicable boxes)
0A4K-ODS9—T-y, j W .
See instructions to determine use(s) for which you may qualify
❑ A. Ordinary household use in one single-family dwelling
_
Mailing address - - -
(no outside use)
JA -%50AV V`14"Kkwl
—_
l�9 B. Ordinary household use in 1 to 3 single-family dwellings:
WIC VATA F,S
Number of dwellings: VNKhl6W iJ
Telephone (w/area code) i E -mea
�1 Home garden/lawn irrigation, not to exceed one acre:
qmro 32z 2
area irrigated 1 7- sq. ft. -1 acre
2. Type Of Application (check applicable boxes)
Domestic animal watering - (non-commercial)
❑ Construct new well ❑ Change source (aquifer)
10 C. Livestock watering (on fans/ranch/range/pasture)
❑ Replace existing well Reapplication (expired permit)
Use existing well ❑ Rooftop precip. collection
7. Well Data (proposed)
-
Change or increase use El Other:
Mmamum pumping rate Annual amount to be withdrawn
3. Refer To (if applicable)
>7.0 gpm 11111040W N acne -feet
- -- --" --- " — --
-
Well permit # - " - I water Court case # -—
zoI5G�-
Total depth Aquifer
-0V -F feet , Mal>1=FFM7 FpR cRT18N
esi
DgnatedaasinDetermination# wellnameor#
8. Water Supplier
{ 95-1
Is this parcel within boundaries of a water service area?[1 YES,$ NO
4. Location Of Proposed Well (Important! See Instructions)
If yes, provide name of supplier:
Courcy - --- -
9. Type Of Sewage System
Pl,�r 5W 114 of ft tf4
-
— ---- - - -� _
Section ( Township NorS R EcrW I Rincipal Mention
❑ Septic tank / absorption leach field
1173 PQ 109W11149 AW
❑ Central system: District name:
Distance of well from section lines (sedien Tunes are typieeMy not property lines)
❑ Vault: Location sewage to be hauled to:
Ft. from i N D'S Z,� FtfrompKE ❑W
For replacement weds only - distance and drachm from old well to new well
❑Other (explain)
feet Direction
10. Proposed Well Driller License #(o tional):
wen location address (Indude City, State, Zip) ❑ciie-& rf wWR address i ssame as in item';.
11. Sign or Enter Name of Applicant(s) or Authorized Agent
0AICRiV6e A1—W WC.0L r�' a
J -t
The
making of false statements herein constitutes perjury in the second
I.A r-�.iMN G(9V XINN I_` OLOItZADO
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
Optional: GPS well location information in t1TM fonrel. GPs unit settings are as follows:
--- --- — -
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
Format must be UTM
T _
_- - - ---- -- son - —. ---- �- �---
neme(s) of persort(s) cation Date (mmlddryyyy)
Zone 12 orZone 13 Easting:Units must be MetersDatum
Uor
Northing:
�..
must be NAD83
Unit must be set to true northIf
Remember to se[ Datum to NAD83
9mng printe namand ON
Was GPS unit checked for above? YES
5. Parcel On Which Well Will Be Located
Office Use Only
reel
current - - _ (You must attach a cunt tined for the subject�
_--
_ __ -- _--
USGS map name DWR map no. Surface elev.
A. You must check and complete one of the following:
❑ Subdivision: Name pAK�'p(-sem gT- -D1/
Receipt area only
Lot 21 Block Filing/Unit
❑ County exemption (attach copy of county approval & survey)
Name/# Lot #
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
& bounds description recorded prior to June 1, 1972, and current deed
❑ Mining claim (attach copy of deed or survey) Name/#:
❑ Square 40 acre parcel as described in Item 4
-- - -
K Parcel of 35 or more acres (attach metes & bounds description or survey)
ACUAMAP
❑ Other: (attach metes & bounds description or survey)
WE
B. # of acres in parcel C. Are you the owner of this parcel?
WR
AYES T'� YES ❑ NO
•
CWca
_-_ ----_----
D. Win this be the only well on this parcel? KYESU I NO (d no - W arm wells)
TOPO
--- - --..-_----
E. state Parcel ID#(oi*onaq:
MYLAR
SB5 DIV WD BA MD