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

COLORADO DIVISION OF WATER RESOURCES
Office Use Only . h! .' Form GWS-46 (0712009)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone -info: (303) 866 -3567 main: [phone]
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Fax: [phone] h :1www.wster.state.co.us
Fax:
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MONITORING /OBSERVATION
Water Well Permit Application
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Review Insttvctions on reverse side prior to completing form.
The form must be completed In black or blue Ink or typed.
1. Well Owner Information y ~� -'
S. Use Of Well
___
comer
Name of wet om
Use of this well Is limited to monitoring water levels
W__ s G2 F'r� is Co lO�edO_____ ___.___ —. ^_
and/or water quality sampling
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7. Well Data (proposed)
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PO
Twat aeptn- - - - --
Aquifer -s—
(�QQX _�_•C —• s� _r�p��._____...---- - -• - --
CAY
36 feet
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8. Consultant Information (if applicable)
Telephoone i jE-Mall (Optl nw)
Nana of contact person
MV) 96 -21 6- 1
AM,? L4,17 -
2. Type Of Application_ (check applicable boxes) _ _
Canpa-my
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•' Use existing well ❑ Replacement for etdsting monitoring well:
OConstruct new well
other: perms n0.-
Mailing address
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3. Refer To (if applicable) _
'-- ___.__,...- _ - -_ -_-
Qty state Zip Code
Monitoring haeadaawledgnrsrd
weilnerneax-
MH-
G W-N 6I
Tebphoras
4. Location Of Proposed Well�lm_portant!
See Instructions_
(?a3) ICY-4707Y
county
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9. Proposed Well Driller License o tional :
10. Signature Of Well Owner Or Authorized Agent
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Semortn Tv"Np N or S
❑
HI- or W Pdndpm wneddlen
❑
The making of false statements herein constitutes perjury in the secwd
degree, which is punishable as a class 1 misdemeanor pursuant to C -R.S.
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244104 (13)(a). I have read the statements herein, knowthe contents
thereof and state that they are true to_�rkrtowledge._
Distance dwell ham section inee (section Snes are lypicAly rat properly IV=)
_
Sign has (Must be odomf signature) Date
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Ft. from N ❑ S FL nom ❑ E W
-1-777 _ —_ 5�'�___ __tom
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_____,._.._ —__._
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Rini —6 ptk
For mplacemenl wets only— distance end dilation from old well b new well
feet direction
—
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Well localien addr9aa andude qry, Stele. Zip)�edt swat address is same as Item 1.
)- ro 90 ovd 2 9d Alut 1 a La �Z
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Offic Use Only _ —_ _
-ev.
— -_._/ -- - - - - - --
Optional: GPS muell location Information in UTM format
USGS map name �D4Kt map no. Surfara
You must check GPS unit for required settings as follows:
-^ - - -- —_ -_ —
Format must be UTM _
- -- - --
-' Receipt area only
O Zorn 12 or 13 Zone 13
Fasting
A10 6L4 /f{ *t
Unft must be Meters
Dalian musl be NADp
Northing
Unit must be sat to Iron north
Was GPS unit eledced for abow9 []YES Remamberto set DatumtoNAD83
Tlov;-41iffibor 8CuSJlI;I?
4l:;iP t.y 11:;3rJ:5f3 i 1k,
5. Property Owner Information
Nemeol �'- - -- -_"-•'--- .__— .__.-- _ -- - - --
opertyyawner
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Tul;ji :;:I.h,,tjni.;j901J.00
steep a� o•� �ho,4
tali_: ;
t�'o _ -'~ _ __ ._
I @r'Iit!tr!I"
L:irl;ti:llFnuU , l71_ JUO_Ui
Mailing address
Al g3_ - --
City Slab Zip Code
Npr~4 C8 _ �%�
DIV _ WD_ SA— MD i
Telephone fh
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