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COLORADO DMSION OF WATER RESOURCES <br />Office Use Only RF- CEIVEG I Form GWS46 (0712009) <br />DEPARVAENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />phone - inro: (303) 866 -3587 main: (303) 866-3581 <br />t mwater.state.coms <br />Fax: 303 866-3569 ht: /lww <br />APR 15 �01� <br />MONITORING /OBSERVATION <br />Water Well Permit Application <br />iAG1TER RESOURCES <br />STATE ENGINEER <br />Review Instructions on reverse side prior to completing form. <br />Co( -o <br />The form must be completed in black or blue Ink or typed. <br />1. Well Owner Information <br />6. Use Of Well <br />Nme awes owner -- --' ""`._-- _ ----- ___ -- <br />i <br />_...,_.. <br />Use of this well is limited to monitoring water levels <br />rr <br />We5re/n rite is LOlorado <br />_ _____--- _- - -, -_- - -- <br />and /or water quality sampling <br />Mailing address -- <br />7. Well Data (proposed) <br />— <br />Po 862 S - - - -- - <br />ooh - - <br />Ll. feet <br />_ - - - -- - -- -- <br />ago ` _ <br />City <br />state <br />Zip code <br />M4 la <br />CO <br />�1 y <br />S. Consultant Information (if applicable) - - - - - -- <br />Name of contact person - <br />9pP -Lw2de ___ _�_ --- - - - - -- - -- <br />_1 <br />Telephone # E-Mail (Options!) - ..- <br />970) " <br />2. Type Of Application (check applicable boxes) <br />Comipary name <br />_ W1fLt_CL1 &e-4 itor 60 - <br />❑ Use existing vml ❑ Replacement for existing monitoring well: <br />McArV adds <br />_ PO BaK <br />IR Consir ict new well <br />El Other. Permit no,: <br />3. Refer To (if applicable) <br />hole Wk awledgment --1 - or# -- — <br />state Zip Code <br />HWntg <br />6W-4.50 <br />Telephone p <br />4. Location Of Pro eel WeIISImQortantl See Instructions) <br />ceUa - - - <br />Moor,— <br />-" — <br />SE 110 of the IV141 „° <br />9. Proposed Well Driller License # o tional : <br />10. Signature Of Well Owner Or Authorized Agent _ <br />The malang of false statements herein constitutes perjury in the second — <br />degree, which Is punishable as a class 1 misdemeanor pursuant to C.R.S. <br />seciwn -- Township N ar S <br />q-7 ®❑ <br />GFr ; -�E orW Pr'indpal Meriaan ' <br />�� ❑ ® <br />+ <br />e' - G6 <br />24-4 -104 (13)(a). I have read the statements herein, know the contents <br />— 'C!'r� <br />thereof and state that they are trot: t, o my knowledge. <br />Distenci of wd from section Free (palectlon sees ere typi -Ily rat property lines) <br />Sign here (Must be ort0taf s4 ature)- <br />7 7 q FL from 101 N❑ S 2 Ft. from ❑ E IM W <br />For replace neMT wells oHy— distance and dnxtlm from old wet to maw well <br />pgnt <br />feet direction <br />,? �ufj p. -Gee% iSt <br />- <br />Well brwton address (Include Crty, State, Lp) aterk if wel address is same as Item 1 <br />Of fi ce Use Only <br />2 6 5 0'gd e.�d Z <br />Optional: GPS well 1=11on information in UTM format <br />You must Check GPS unit for required aeltings as follows: <br />Receipt area only <br />Format mist be 11TM <br />D2me12or 0 Zone 13 <br />Eestirp <br />/Q /y�/,ff <br />Units must be Maters <br />Datum must be NADq <br />Northing <br />Unit must be set to true north <br />Woe WS unit checked for above? ❑YES <br />I Remember to at Detum to NAD47 <br />in,rt'r•;'f��itrf ri:l :i(irt Sll l;•c:' <br />S. Property Owner Information <br />Nome of property owner <br />T'oi.idl aimr filuL'y"fif3il.D0 <br />Maisrq aeditea <br />PO Sox X32 <br />city - state Zip Code <br />Norwood GO $1 V 29 <br />DN_ WD_ BA_ MD ` <br />Texlphore0 - ^� - <br />( ) <br />_ 34,Y929a -A r-02 4an1T1&w,4-L lmco <br />