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"SS r' 1= i1 /I_ I'. <br />COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only Form GWS-46 (0712009) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />APR 16 2011 <br />phone —into: (303) 886 -3587 main. (303) 866-3581 <br />For- 303 866-3589 http:1Avvw.wsIer.staIe.co.us <br />"r► W W <br />MONITORINGIOBSERVATION <br />Water Well Permit Application <br />Review Instructions on reverse aide 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 />I4erneotwdowrcr � ---- ___.��^_._._ - -- <br />.. <br />Use of this well is limited to monitoring water levels <br />_ We stern Fue/.s C �4 __— _- - - - - -- - - - -- -- <br />and /or water quality sampling <br />7. Well Data (proposed) <br />lNelNroeadrase <br />_ __ <br />��h <br />Po Box <br />_ <br />feet <br />1 Lf <br />State Zrp oode <br />(}ty t <br />N, da i <br />S. Consultant Information (if applicable) <br />_ —ce <br />Td +ro k E-deptsalr----�— ppNmel) <br />Name ar contact peraon....—..____--- _..�— ��..__._----- -- ---- -- ---- <br />qw) <br />- <br />2. Type Of Application_ (check applicable boxes) <br />❑ Use eldstingwell ❑ Replacement fore)dsting monitoring well: — <br />_W_ erfw/) Fuels ..__ <br />Mailing address <br />�� y _ <br />Construct new well Permit no.: <br />❑ Other. <br />3. Refer To (if applicable) <br />Mertitortrghaleacknowedgment - WelrrmrnearM__Q - -- - <br />Cdy stele Zip Code <br />er11er �Q _ �0Z� �`�, <br />MH- ! ! <br />Tdepharo A <br />(1 ) 2,0 - 30 7 <br />4. Location Of Proceed Well Lm igtantl See Instructions) <br />"- — ` y '� --` —��� <br />r <br />IJ 14 <br />8. Proposed Well Driller License o tiona : <br />1_0. Signature Of Well Owner Or Authorized Agent <br />The making of false statements herein constitutes perjury in the second — <br />degree, which Is punishable as a loss 1 misdemeanor pursuant to C.R.S. <br />44atrstrose, <br />—�Y—k✓ 1f4o1e" Lj� <br />section+ <br />25' <br />Towutlup N a s <br />1� <br />Range E orw Principal McAdwn <br />❑ 14 <br />ff T,7 P4 P411 <br />16 M - <br />24-4 -104 (13)(a). I have read the statements herein, krwwthe contents <br />et tr _ <br />thereof and state that they are true to my knowledge. <br />Distance d well *am sec lon lines (sedon Tiros we typically not property lines) <br />7 Ft from PQ N ❑ S / u �r Ft ft. ❑ E CKW <br />—wall — <br />___ <br />Sign ties (Must be orlg. signature) <br />7 <br />Dale y <br />For repfacefront weirs ority - Aelena anddi won harm cidiwall Do r+en <br />-- w__ __ __ -- ---- — <br />Print name tltle <br />feet direction <br />Lwde - G eo! o lsr- <br />wdi eaeonads eee (include t ry. store np) Chalk It wall address is same as rein 1. <br />L 0 <br />Offich Use Only <br />Oprlowl; GPS well ioC8llort i fannabon In UTM formst <br />You must check GPS unit for required settings ss folows: <br />U '" ro +(�map no. - Srrreoe dev. <br />- <br />Foment must be UTM <br />Receipt area only <br />0 Zone 12 or Q Zone 13 <br />i <br />A/O M �----- <br />Unils must be Meters <br />On= mart be NADW <br />Northing <br />Unit must be ad 10 tee nomh <br />Was oPS unit sacked for above? ❑ YES <br />Remember to set Datum to NA063 <br />i I - +l r•, :') t!I' I I.li I . i(iA : •f ('! jC <br />i;1';!1'n ; l i,114",y l,M <br />►ut:,i :'r;irr =.lout $EipD.OG <br />S. Property Owner Information <br />NameofPAWtyd�rar <br />�t7 %� � L G losie•- <br />- -- -__ - -- <br />MalNrrg address <br />'.i7k(;IIIItJIfIIJI'V. �2Jjij <br />PO v <br />Clly staat Zip Core <br />N /a 6° ___ l z y <br />DIV_ WD_ BA_ MD <br />Telephone A <br />S4f- wAo <br />