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COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only r: : Form GWS-46 (0712008) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />phone - Info: (303) 866 -3587 main: (303) 866 -3561 <br />Fax: 303 866 -3589 h":1/www.%water.state,co.us <br />qp� 5 20f� <br />MONITORING /OBSERVATION <br />Water Well Permit ApplicationT�q� <br />Review Instructions on reverse side prior to completing form. <br />The form must be completed In black or blue Ink or typed. <br />1. Well Owner Information <br />6. Use Of Well •------.._..._____ - -_ -- <br />_ -__ -- <br />Name u#wel owner <br />We fl ern Fwe CO /prpdd <br />Use of this well is limited to monitoring water levels <br />and/or water quality sampling <br />uathng addren <br />P0 86K <br />7. Well Data (proposed) <br />City ! S, /tea -- - �o�e -- _n <br />Nabs ! C 2 <br />0 feet of� <br />8. Consultant Information (if applicable) <br />-.--. <br />Now of contact person <br />R4&7 C n <br />Telephone N - r E -#t-al (Optional) <br />(170 6q-2r6S <br />2. Type Of Application_ (check applicable boxes) <br />- -- - <br />Comparry name <br />_We41Y'1W <br />Mallingaddress <br />❑ JIse existing well ❑ Replacement for existing monitoring well <br />Constnrctnewtwell Permit no.: <br />[I Other: <br />_ POad 3 3 q - - - - - -- <br />Dry stale – zipcode <br />3. Refer To (if applicable) <br />►lodlodrV nde adgwMeaoment <br />i <br />MH- <br />- - - -- ---- -- <br />? <br />( ?� <br />4. Location Of Pro op sed Well (Importantl See Instructions) <br />- - - -- - - - -'- <br />9. Proposed Well Driller License #(optional): <br />c«. — <br />/4 ,0nf1-cS& NW 1/4 of o- WW 114 <br />10. Signature Of Well Owner Or Authorized Agent <br />Section � Tomnship N or S Range -- E sr W pr+napal meridian - <br />�. q7 ❑ ❑ �/ <br />�— <br />--------------- ____ - -__ _ – __—.......__..__.-- - - - - -- <br />The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S. <br />24-4 I have <br />/&W )9eXiGb <br />-104 (13)(a). read the statements herein, know the contents <br />Dustance of well Ban section lines (� on lines ale typically not prapedy lnes) <br />70 Fl. hoes rN ❑ S 660 Ft. from EAw <br />thereof and state that t are true to knoWled e. - <br />Sign here be oripinar sigrehte) Date <br />1 <br />Avm Z V7111 <br />Print name &sae - --- --- - -- ---- -- ---- • -__.__ <br />For replacernard wells only - distance and dracem from old well to new well `-- -- - -- -- - <br />feet -per direction <br />-- <br />a /J e � f eO /O jar <br />Lan `nl V <br />Well location address (InOxIs. Gry, State, Zrp} u Chscic if well address is same as Item 1.. <br />Office Use Only <br />- <br />USGS map <br />Optional: GPS well location informatian in UTM format <br />You must check GPS unit for required settings as folowa: <br />- <br />name DWR map rw. suitece elev. <br />- -- - - - - -- <br />Fomlat moat be llTA1 - - -- -� <br />D Zane 12 or O Zorn +3 <br />__-- -- -- --- ---- - - - -- <br />f Fasting <br />Receipt area onl�- - - - -- <br />Unho must be Meters <br />Datum must be NM83 <br />I <br />Northing <br />Unil must be set to true north <br />Was GPS uetchadad for above? [:]YES <br />Remember to not Datum to NAD83 <br />f l;,lt�, hluu)bl.l: ;tli�isiLlfl2 <br />3. Property Owner Information <br />•11i;;f':(I i .I , , , <br />Nerrcdprop" Mwner <br />Tta:fr irlx r.; 1: $'90r,.fju <br />Mailing address �I <br />_ rQ Boy . -- -- -- -- - _ __ -- <br />D(V WD BA MD <br />aty State Zip code <br />N ao, _- _ (0 A1y� -- <br />Telephone# <br />( ) <br />56�-5 30jr go ga A Fez A7a.faKak t: in,Qo <br />