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COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only R- ECC I�. E#orrn GWS-46 (0712009) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />phone - Info: (303) 866 -3567 main: (303) 666 -3561 <br />�pn y C <br />PR <br />Fax: 03 866 -3589 :Ih~.water.state.co.us <br />O+i <br />1 5 t <br />VATER REAR <br />MONITORINGIOBSERVATION <br />Water Well Permit Application <br />S <br />STAMr: INFFsy <br />CON- <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 />or <br />e,ro a <br />Nwelowner <br />..___ <br />Use of this well is limited to monitoring water levels <br />W,05teM Frials Golaradb <br />and /or water quality sampling <br />Mainrgaddrwa ---- --------------- .---- ______ <br />7. Well Data (proposed) <br />pig <br />- <br />feet <br />�o�o <br />NGL�Lj G� Si(,Z -� <br />'" _ -- — <br />8. Consultant Information (if applicable) - -- _ - - -- <br />Name or mnlau person <br />raepn«ra • e-usl (opoongl) <br />(170) 86 y-�J�o yr <br />OQW 0 L.46-2de, <br />-&;Znynwm <br />2. Type Of Application (check applicable boxes) <br />_ We ft&-l7 raeIS_ 45sa ei'1 __ <br />❑ Use existing well ❑ Replacement for existing monitoring well: <br />® Construct new well Permit no.: <br />❑ Other. <br />Mailing address <br />PO R& <br />3. Refer To (if applicable) <br />ay state Zip Coda <br />_ <br />__ ,DCi rer- _ CO <br />M"onng Ise acknowledgment <br />weu rome wa <br />MMP- TV <br />vl W -/f%rJ� <br />Telephone A <br />Qa) 2 -73 <br />4. Location Of Proposed Well Im <br />4. See Instructions_ <br />9. Proposed Well Driller License o tional : <br />County - "- _-rtantl <br />5167 174 of to 114 <br />10. 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 />serslon Township N of 5'— <br />�} /,L 7 ❑ <br />Range E or W Pnndpel Meriaan <br />r/ ❑ � <br />.0 �J T I <br />! 6 NeV Alla&V <br />244104 (13)(a). I have read the statements herein, know the contents <br />. -_ ~ -_' <br />thereof and state that they are true to my kno *fie.__— <br />Dismnce of wee from section lines (section lines are tyf*nly not property Ines)-- <br />Sign here (Must be odgiha, signature) ` Dalee <br />f 7 8 q Ft from [M N ❑ S 2 6-6-C Ft from ❑ Egg W <br />lredl (icemen <br />For welt; or y- astance and dnxvm rrom old vmil bo �v well <br />_ —_�! <br />priin s fine - -- - -- <br />feet direction <br />-- <br />pp <br />�� u G D /� r <br />Wsl1 locetan adders (Irdude Gy State. Zip) ❑ Check tr wel address is same as Item 1 <br />Ice Use Only <br />e <br />.6 6'0 o4 Z Ad /If____utl� 1 � <br />-- - - - - -- <br />�p pyyR map no- Surface ayv. <br />_- - - - - -�� -- <br />_Ld <br />—�1� <br />Optional- GPS wall location f�nr__�- mxa__t_- __n____In__UTM torrnat <br />You must check GPS unit for required settings as follows -- --- - -�___ -�- — <br />Forhr�asrrustbeuTM <br />Receipt area only <br />❑ zone 12 or Q Zone 13 <br />Easling <br />` M� <br />/,,YO # <br />Units murk be Meters <br />Datum must be NADes <br />Northing <br />Unit must be set io bus north <br />wssGPSw*chadkedforahwe7 ❑YES <br />Remember to set Datum toNAD87 <br />i• t;, -l;;� {,:ii;te+l.;�fitffllJ }i1•� <br />1,'1:tlril i 1 1.;3ft;i,y r.i.t <br />5. Property Owner Information <br />Narro of prop" cas,er <br />I t:r:, e,•:j, i it l: <br />tat i:,f„t,t: lfhU•i�U <br />J1ieehie Pew Jo aid r s <br />tla'fl (: <br />_ _ — __- - - <br />Mailing address <br />(ti,;: is du.ul,k §r: 11y+t9 <br />- -- - —N%?-- <br />P fox 33 -- - - - -- - -- <br />Cdy state Zip Coda <br />IYorwevd Go 91Y;3 <br />DN WD BA MD <br />Telephone u! --� --- <br />S� 3G y$o92 -4 foz 4bD,Tfew•4e- .Avdc <br />