2014-05-12_PERMIT FILE - C2010089 ‎(8)‎

• Permit No: C2010089
• IBM Index Class Name: Permit File
• Doc Date: 5/12/2014
• Doc Name: Approved Well Permits
• Section_Exhibit Name: Appendix 2.05.6‎(3)‎-4
• Media Type: D
• Archive: No

gx25,k
COLORADO DIVISION OF WATER RESOURCES
Office Use Only Form GWS-46 (07/2009)
OEPARTIiGENT OF NATURAL RESOURCES
RECE IVEL)
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone - Info: (303) 866 -3587 main: [phone]
Fax: [phone] hftpJVwww.water.staIe.co.us
APR 15 2011
MONITORINGIOBSERVATION
Water Well Permit Application
WATER RESOURCES
Review Instructions on reverse side prior to completing form.
STATE FNGINEFp
Coto
The form must be completed In black or blue Ink or typed.
1. Well Owner Information
S. Use Of Well
Norm of well owner
Use of this well is limited to monitoring water levels
W 60el-17 F l
andlor water quality sampling
Malmo address
7. Well Data (proposed)
r my - sale _._. �a _ - - - - -- - —
- Total depth
) -1-
T 7 feel Q /f Bfit�
Natla 60 q/ 7� !
8. Consultant Information (if applicable) _ µ
.— _._�_...._
Telephone a - -�_T e-mail (opional}
Name of mnlad pewon
Luy7 de
(170) 8 ,t_ z
R _o
""-
2. Type Of Application (check applicable boxes)
- -- -- -- --- - - - -__
cogmmdme
❑ Use existing wel ❑ Replooemenl for existing monitoring well: _
A—
_ -_ we ff --- - - -__— _
gConstruct flew well Permit no.•
❑ Other
M,�ng
16
-nzip
3. Refer To (if applicable)
City code
Monitoring hale adwaaledgrront �--' Well name or it� _ .._..__.._.__.. —._-
p���p ( /Staattee1 Q
-- Ci•4!!JI•irr ---__--- -__-- yf��t_92 - -Zdr_
M H- G W- N y D
Telephone a
(409) 25"t-?073
4. Location Of P %dosed Well Im ortand See Instructional
— --
County -'
N 1,/ 1r4
9. Proposed Well Driller License o tional):
10. Signature Of Well Owner Or Authorized Agent -
The fnaking of false stetemef>ts herein Constitutes perjury in the second
114 of /
M 012 tr05e
$ecllon yT Twmshp - N or S -
Range - E or W! Pdndpel Morldan
I 7 ❑
i�i-
I / ❑ f eie Alexll o
degree, which is punishable as a dass 1 misdemeanor pursuant to C.R.S.
244-104 (13)(a). I have read the statements herein, know the contents
I
w _ _
thereof and state that they are are tnfe t�krawtedge�__
Distenee of wall from section lines (asclon fines are typkaly not property lines)
_
sign here (Must be e�Y� tll�+re) Date
Ft tram Dk N ❑ S / {t Ft. ft. ❑ E CQ W
Yhmo `mod
/7/
•-PAnt &Iftb- --- -- - - - -- —' ---
For replacernen web only - distanos and direction old to row well __�.-- - - -.•-
feet direction
/?%9,7 e Gen l � s
wet laalon Wdess Pndude city Sate, Zip Check If wel address Is seine as Item 1,
ZRd a.,d -Do,Qd /�/r�clo_C 0�!Z -
-- -
n
offic use Only
USGS map name DWR map no' psurf�°° elev.
optional: GPS wet! location information in UTM format
You must check GPS unit for required settings as fogowa:
- - _ _ —
r- ^-�-
Formof must be UTM
Receipt area only
17 zone 12 or O zone t 9
Fasting
Units must be, Maters
Det M roast be NAD83 Northing
W mast be M lo rue. norm
I
WnOPBunkchec edforebm? ❑YES Remember to set Datum toNAD8]
fYfyll i Itl(ffl'It)Gil; .ffirl;l�i! {'lrf
,rt "J'91i t -I 1 • :7ii.; >si I M
IUtt�l )Ikflr. l�rflk $tiUq.t)()
5. Property Owner Information
Name of property owner _
F L. GlQSiCr
_(7Epr9C•
Melfrrgaddraae
t E ilur :i; {u_�uu�•t(_._ t
— -
PO ox 9 s__ -- --
-- -- - - - ---
on state zip code
G0 $12.4
otv! WD v RA` MD
TaMptwneN