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Form No. <br />GWS -68 <br />10/2011 EXISTING WELL INFORMATION AND INSPECTION FORM <br />Division of Water Resources, 1313 Sherman St., Ste 821, Denver, CO 80203 <br />PLEASE COMPLETE THIS FORM IN BLACK INK <br />PERMIT NO: ZotS(o4 RECEIPT NO: 0+11069 A DIV: 'k WD: 3Q <br />Existing Well Location: SW '/< of the Sl, '/4, Sec. , Twp 34_SNI Rng 9 W , 0 P.M. <br />i(,b feet from N(Tgec. line, Z30� feet from the( sec. line; County t -A P�QTI� <br />Existing well owner: Name: 04Y-T2t'DC� V�mtq�&y I INC_ <br />Mailing Address: 4,rol3 .J (_ (S 1$tC' HWW&V <br />City/State/Zip_ tviCHtTA t=A.Ij5S,►X 1143ol Telephone: (94Q) aZ2 <br />Description of parcel (subdivision, lot, blk, flg) jJ5r7_+ Size 35-1- ac <br />Existing well location and visual conditions: If stating no, please explain <br />Type of Existing Well rifled and Dug, Spring Well, Gallery Well, Gravel Pit, Other <br />Distance to nearest septic tank/sewer line (approximate) -;;- ?, <br />,,CUD feet <br />Distance to nearest leach field (approximate) 72,0 feet <br />Is the well in a clean and sanitary location? ytx:�> <br />Is the well maintained in a clean and sanitary condition? y> <br />Is the ground at the surface sloped away from the well for proper drainage? \'joz ' <br />Is the surface surrounding the well firm and stable? \1 <br />Is the well situated in a well house or vault? NO If so, is the well house or vault in good repair <br />and condition? <br />Existing well construction and materials: If stating no, please explain <br />Is the well equipped with a sanitary wel ea ap? t5 ( <br />Is the well constructed with steel casing at the surface? j+zS <br />Does the casing extend at least one (1) foot above the surface? %4 > <br />Casing size 9' O.n_in; Estimated well depth 30j- feet <br />Who constructed well? 5rex1im sl�Z,Tf*► LAA_ eoT?A ; Who installed pump? uta►eN*jgjtJ IF FV*tM <br />Current uses of existing well: Were the existing uses initiated prior to May 8, 1972? NO <br />Household use in single-family dwellings <br />Watering of poultry and/or domestic animals <br />Watering of livestock on farm or ranch; approximately how many head? <br />Is this a feedlot? ; How many head? <br />Lawn and/or garden square feet <br />Crop Irrigation acres <br />Fire Protection <br />Commercial exempt for <br />_Other: MoNfT?9i2a��-wrt� <br />Estimated date well constructed /Igg3 ; Estimated date pump installed MW&OO <br />Estimated date of first use �Ny-N&,ot,3 ;Estimated flow rate Z0 gpm <br />How many other wells are located on this parcel? _ 0 Uses: <br />Permit/Case Nos.: <br />Existing Well Owner Signature: ' , � 7&K Date: c , <br />---------------------------------------------------------------------------------------------------------------------------------------- <br />Has information above been verified? <br />List any problems you have identified. <br />Date of inspection: _ <br />Inspected by (print): <br />For Office Use Only <br />If not, please note accordingly. <br />(if none, please state so) <br />Phone Number <br />(signed): <br />Attach photo(s) if available or needed for further evaluation. Additional comments or information on back. <br />