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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: X02084- RECEIPT NO: 041311-(x? DIV: -4WD: 30 <br />Existing Well Location: 50 '/4 of the 51- 1/4, Sec. _, Twp34-SIJ, Rng 13W 0M P.M. <br />llSO feet from N S9ec. line, 12U0 feet from the0V sec. line; County <br />Existing well owner: Name: OA>4VA-QG0 gjg2:jG-`(, ►WC_ <br />Mailing Address: 461_S J /ACU_- > lA I G.Nti Al ( <br />City/State/Zip WICIArM !E&jAs--2 11 M �-6 ?,o 1 Telephone: (Eqy ) 3 2 — 4772— <br />Description <br />7ZDescription of parcel (subdivision, lot, blk, fig) 0AK1zIT)6,V err 'DVPANGO .; Lm 3A: Size _�s� ac <br />Existing well location andYisual conditions: If stating no, please explain <br />Type of Existing Well:Qa2gand Dug, Spring Well, Gallery Well, Gravel Pit, Other <br />Distance to nearest septic tank/sewer line (approximate) 51 0o feet <br />Distance to nearest leach field (approximate) > 3,©o0 feet <br />Is the well in a clean and sanitary location? _�jgc> <br />Is the well maintained in a clean and sanitary condition? y0_�> <br />Is the ground at the surface sloped away from the well for proper drainage? ye"s <br />Is the surface surrounding the well firm and stable? 4125S <br />Is the well situated in a well house or vault? Nb 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 s ap? spy--g- <br />Is the well constructed with steel casing at the surface? 4g!S <br />Does the casing extend at least one (1) foot above the surface? WsO---> <br />Casing size 101 O.P. in, Estimated well depth 480 feet <br />Who constructed well? PVorT ,Xo COAAL, INC- ; Who installed pump? f-.. Ek''>;AAA <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. M&jje-rEg2_jKu--wt_q,4 <br />Estimated date well constructed V-1 ; Estimated date pump installed ►O�lg$3 <br />Estimated date of first use _ t1/19;;32; Estimated flow rate ►SO gpm <br />How many other wells are located on this parcel? _ 0 Uses: <br />Permit/Case Nos.: <br />Existing Well Owner Signature: Date: 1 <br />--------------- <br />For Office Use Only <br />Has information above been verified? If not, please note accordingly. <br />List any problems you have identified: (if none, please state so) <br />Date of inspection: _ <br />Inspected by (print): <br />Phone Number <br />(signed): <br />Attach photo(s) if available or needed for further evaluation. Additional comments or information on back. <br />