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COLORADO DMSION OF WATER RESOURCES <br />Office Use Only Form GM 46 (11,2011) <br />OF NATUR RESOURCES <br />113 <br />S Ste 8821 DENVER CO 80203 <br />RECEIVED <br />Phone: 865 -3581 Fare 303 8W2222.gXU2UgjLqgL1DS2gAjqa.A <br />MONITORING/OBSERVATION <br />MAY 17 2013 <br />Water Well Permit Application <br />Review Instructions on reverse side prior to completing form. <br />HATER itt5 INFER S <br />STATE ENGINEER <br />The form must be typed, completed online or In black or blue Ink. <br />1. Well Owner Informatbn <br />Nam of Well onew <br />6. Use Of Well <br />Use of this well Is limited to monitoring water levels <br />Wester Fuels Colorado, A Limitted Liability Company <br />and /or water quality sampling <br />MWM*dftu <br />1100 W. 116th Avenue <br />7. Well Data (proposed) <br />CIY <br />Stw Zip code <br />Tom daps, <br />AgAler <br />Westminster <br />CO 80234 <br />102 feet <br />Dakota Formation <br />Twwwms <br />E -Mali or filling allnedisrequired) <br />8. Consultant information (if applicable) <br />Nameof=%Wparaon <br />Douglas C. White <br />303254 -3208 <br />mgsorensen @tristategt.org <br />2. Type Of Application (check applicable boxes) <br />❑ Use axlsting well ❑ Replacement for existing monitoring well: <br />Company rwne <br />Construct new well <br />Westem Fuels Association, Inc. <br />Permit no.: <br />❑ Other: <br />Me" address <br />12050 N. Pecos Street, Suite 100 <br />3. Refer To (if applicable) <br />MoNtodno hw <br />Wd naro or N <br />CxY <br />su" <br />Zip Code <br />MH- <br />GW -58 <br />Westminster <br />CO <br />80234 <br />4. Location Of Proposed Well (Importantl See Instructions <br />Tw h" a <br />303 255 -5806 <br />C- <br />Montrose <br />SW 'Hari° SW 114 <br />9. Proposed Well Driller License o tiona : <br />Seesa, <br />Towndap <br />Nor S <br />Rape <br />EorW <br />PnndpalMendan <br />10. Name of Well Owner or Authorized Agent <br />25 147 <br />Ili f <br />16 <br />n go <br />I <br />New Mexico <br />I <br />The making 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 />24 -4-104 (13)(a). I have read the statements herein, know the contents <br />oismnce of wall hero saiMan lines (sedon Iron are typically not property lows) <br />thereof and state that they are true to my knoyuled e. <br />754 Ft. from( N is S 55 FL nom r; E W <br />Slgn a nine here <br />Data (rnnvddLYyYY) <br />For repkwment wells ally - dtslame mud duecam ham old eel to new wall <br />feet direction <br />a sprurp print Print live H other Ihert owner <br />C hrk SMt%s� t ts�G+k� caftne •tvva- A r A6 4 GwA t <br />Wall loeabm address (Include (]b. Side. Zip) OchiagFiesNaddressisserneashervii <br />2600 and AA Road, Nucla, CO 81424 <br />Office Use Only <br />Optional. GPS well location information in UTM format <br />You must chedt GPS unk for sequined ssttinga as follows: <br />USGS crop name <br />DWR map no <br />5larece war. <br />Fomet must be UTM <br />r3 zone 12 or 13 zee is <br />Eating <br />L <br />Receipt area only <br />Win met be MOMM <br />/qK <br />Daiwa nest be NADas <br />Northing <br />W mat be sat m Itre rarnh <br />3 W S V <br />uses lips halt errsrled nor sbovso ❑ rES <br />Remember to set Datum to NAD83 <br />w <br />0" .u) % <br />Na Z <br />5. Property Owner Information <br />Nara prapaly owner <br />Garvey & Co., LLC <br />Tr <br />nsection mlr: 3950054% <br />Mal`a° address <br />P.O. Box 555 <br />Transaction Total: $300.00 <br />CRY <br />state <br />Zip coda <br />Nucla <br />CO <br />81424 <br />CREDIT CARD $300.00 <br />q PO <br />Telephone # <br />DIV WA BA , MD _ <br />970 864 -2243 <br />