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COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only ieorm e3WS-46 (07/2009) <br />DEPARTMENTaOF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />phone — Info: (303) 866 -3587 main: (303) 886.3581 <br />APR �pp <br />1 5 2011 <br />Fax 3 8663589 htI : /Awwvwater.state.co.us <br />wiMW E S ups <br />MONITORINGIOBSERVATION <br />Water Well Permit Application <br />COLFII <br />Review instructions on reverse side prior to completing form. <br />The form must be eompkited In black or blue Ink or typed. <br />1. Well Owner Information -__- <br />6. Use Of Wei <br />Use of this well its limited to monitoring water levels�� <br />Nae w awns _ _— .______ -_ _______� <br />m da <br />Weoerf) F ,{ — <br />and /or water quality sampling <br />7. Well Data (proposed) <br />Mailing address <br />Po 4ox 6 2 Q <br />Tait d<pr� - <br />,,�fe<---------- -- - - -- <br />City -- - -- Stare Zip code - - - - — <br />fee t <br />65 i <br />Qh�fd/ <br />0 <br />Axle CQ �i z q <br />`_ ------ <br />8. Consultant Information (if applicable) <br />--- ----- <br />Name - <br />Telephone #� E-Mail <br />(970) <br />--- -- <br />2. Type Of Applicatlon (check applicable boxes) <br />�/1%efJ�M —/ WB fi �Stxipr•G�7 __ _ _.�___ <br />_ <br />❑ Use existing well ❑ Replaoemenl for existing monitoring well: <br />Mailing address <br />_Po A* 33 �f z 3 <br />�-- <br />Construct now wall Permit no.: <br />❑ Other: <br />3. Refer To (if applicable) <br />pty slate Zip pCCode <br />An7rL r 60 1 Vl� i •. ! _� <br />Monitoring holeaclawAscIgment <br />w6W <br />MH- <br />-h S 5- <br />Telephone R <br />)-2 Sy-3073 <br />4. Location Of Pro sad Weil Qmportant! S_ee Instructi=A- <br />County —�� <br />Count <br />� <br />-� — <br />S �✓ /(� � 1M <br />9. Pro d Well Driller License o tional : <br />10. Signature Of Well Owner Or_Authorized Agent <br />riN'OSe <br />1w of the <br />section Tcwnshp -- 1 or S -- <br />j .�, .'.'� 0 ❑ <br />s�sf ! <br />Ikinia -- E or W pdndpa Meriaan <br />❑ <br />The making of false statements herein constitutes penury in the second <br />degree, which Is punishable as a class 1 misdemeanor pursuant to C.R.S. <br />24 +104 (13)(a). l have read the statements herein, know the contents <br />thereof and state that they are true to mfr krwvAedge. <br />Distance dwell from sedan Imes (sedan Imes are tip nd property foes) <br />—____ <br />Sign here (Must be angry/ dgmtune) - <br />Data <br />Ft tram ❑ N S Ft trom ❑ E ® W <br />l QS � rf l _ <br />For replacemerawe llioNy- dalam and direc tionfromaid well tonewwell <br />print iW(eIuse —_� - -- — ._�- - °- -� -- -- -- <br />feet direction <br />Q I u /�O�D S 1, <br />�i L 6 <br />Wet location address (Imllde pry, State, Zip) Cheek M wet adYe6616 6emB as Item i <br />Z�� Ir0 t <br />Office Use Only <br />!4.,- d,- 1A --- _ - -� <br />US65 n,ep name -�� -" - <br />- <br />p n�e�i no. <br />surface dev.� -- <br />Optional: GPS well location irlrormation In UTM format <br />You must check GPS unit for required setting% as follows: <br />- -- - <br />Fomlat itim be UTM -"-- --- I <br />- -_ - -- Receipt area only <br />O Zone 12 or 0 Zone 13 <br />Ea9ting <br />�/o p t <br />Unite noel be Makers <br />Datum must be NAD43 <br />Norlhiig <br />Una rtust be set to true north <br />WaGnunitchedW11"abova? []YES Remember to not Datum to NAM <br />('el3nr,Nt!::li_,tf: iliAsilili'� <br />- v1j,/: l:rii 1 39."li! I'M <br />5. Property Own er Information <br />Naned prop" owner- <br />� 1uttil rl::7t;; Iili:L �plil).DO <br />6itQ cO <br />-- <br />Check lA�;fitIt;r:�: 379+10 <br />-ate! _ - - <br />— - - <br />po &fox I « —___ <br />Pry state Zip Cade <br />Arc lq GO 8/ V2 y <br />DN 1ND BA MD <br />Telephone "" °_�.__._._. —• —_ —� <br />( ) <br />1 JW \5k) i-, sct>" <br />562-- 3 &y9s19.-L A r-oz 4a,)rrwv*c. -"xo <br />