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 Forrn GWS-46 (0712008)
DEPARTMENT OF NATURAL RESOURCES
RECE ,
9313 SHERMAN ST., RM 818, DENVER CO 80203
phone — Info: (303) 866 -3587 main: [phone]
Fax: [phone] : /hvww.water.state.co.us
APR 1 5 2011
MONITORINGIOBSERVATION
Water Well Permit Application
tAY1TER RESOURCES
Review Instructions on reverse side prior to completing form.
STATE E INFFP
t;OI
The form must be completed In black or blue Ink or typed.
1. Well Owner Information
6. Use Of Well
-.
Use of this well Is limited to monitoring water levels
'
and /or water quality sampling
l tinny edd"ss
7. Well Data (proposed)
�pn► /►�
PO O!` 6.2
Total depth
V
��
feet
96
Op/Lf7�A
aty zips
e
Nv aA 1 60 `tz?
S. Consultant Information (if applicable)
— _ -`--~
7deptwneR --' -M i E-0lail(Optlon�)
R702411-2/45- i
Name of carted person
_R a� Garde
2. Type Of Application (check applicable boxes) —
CORD name
\,Ve -5t n Fuels Asot-oftox
❑ Use existing well ❑ Replacement for existing monitoring well:
-
nailing address
-- phi �D� — 113 __ --
® Construct new well Permit no.:
❑ Other:
3. Refer To (if applicable)
°� CO tate Zip code
rJt/l?�` G
- -- __— _____.____
rtrhpndeatleholedgrtrart lnkleame;5
MHtc—
6W- y J y
Telephones
4. Location Of Proposed Well IYmpoftantl -See Instruction-
-counv � -` - -` -
/i'�Ont�os2 S W '14 Of the /J/ h/ - "4
(03) 2 11-307 3
8. Proposed Well Driller License # o tional :
10, Signature Of Well Owner Or Authorized Agent
section Ta►netsp or - Range E or W' Prindpal We dies
The making of false statements herein constitutes perjury in the second
2 47 '. ❑ 1 ❑ ;
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4 -104 (13)(a). 1 have read the statements herein, know the contents
- ,'Q+
_;^
thereof and state that there true to my ktwrMedge_—
Distance of was trom section Ines ( section Ines are typicely not Property lam)
'174 Ft arum ❑ N CR S j' Ft tram ❑ E IJ W
--
Sign here (Awt'be wrpyral sigrwure) Dace
/ ,
/� *`J�� q11 r 111
For replacement wells only - distance and direction Iran old well to new well
Print name & Me -- - _`-
feet _ direction
wail locauon address (include Cdy, Stets, Zip) Check if well address i3 same as Item 1.
Office Use Only
�
USGS map name —� `_ _— _ DWR map no. Solace ev.
Optional: GPS wail location I fo�n U M fomtat
You must check GPS unit for required seltrngs as falows:
I
Jv
Formal must be UTM
Receipt area only
I
l7 Zone 12 or O Zone 13
i
%
/( �0 4
Untie must be Meters
pecan must be NADU i
� Northing
!
Unit must be set to t ue north l
Was GPS u it chedked for above? []YES Remember to set Datum to NAD43
� I.aI,: I�::lrlilliTl: 3GrISttl!,,
5. Property Owner Information
Nameapreparryawner
6keez and 60
1 Dull I,,,uc.,�,rtt yi,G.uu
-__ ----- t• 11i14in -AfafUt7Ftr- -- ;�fiti'ti�1'__
DIV_ LVD_ RA _ MD
Meing address
Pa sax I/ _
City /Uaclo co 61316 �iy�
(e,,, —nee
5 6�f- 36 Ygg9,2 A ANe AM)/ c- '.vro