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RESOURCES <br />OF NATURAL <br />office use only F°"" rN"s as (11/2011) <br />DCEEPA�RR�NT RESOURCES <br />RECEIVE <br />1313 SHERIMAN ST., Sts 821, DENVER CO 80203 <br />Phone: 03 868 -3581 Fax 303 866-2223 lire <br />MAY 17 2013 <br />MONITORINGI'OBSERVATION <br />Water Well Permit Application <br />WATER RESOURCES <br />STATE ENGINEER <br />Review Instntctl an <br />ons on reveres side prior to cpleting form. <br />CQLO. <br />The form must be typed, completed online or In black or blue Ink <br />1. Well Owner Information <br />Nam °rvall awrm <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />Western Fuels Colorado, A Limited Liability Company <br />andlor water quality sampling <br />mourvaddre" <br />1100 W. 116th Avenue <br />7. Well Data (proposed) <br />cry <br />stale <br />ZIP Code <br />Tom dooth <br />Mow <br />Westminster <br />CO <br />80234 <br />85 feet] <br />Dakota Formation <br />dwi—mv <br />rAl (If ling itwreadred) <br />Information 8. Consultant Infoation ('tf applicable) <br />Nrere of contact Pin <br />Douglas C. White <br />303 254 -3208 <br />r4sorensen@tdstategt.org <br />2. Type Of Application (check applicable boxes) <br />* Use existing well ❑ Replacement for existing monitoring Well: <br />corn "no" <br />® Construct new well <br />Western Fuels Association, Inc. <br />Permit no.: <br />I] Other: <br />Mailing addrsw <br />12050 N. Pecos Street, Suite 100 <br />3. Refer To (if applicable) <br />• <br />Will norne or ill <br />(qty <br />Sift <br />Zip Coda <br />MH- <br />GW -57 <br />Westminster <br />CO 180234 <br />4, Location Of Proposed Weil Im ortanti See Instructions <br />Tolopho nee <br />303 255 -5806 <br />M <br />Montrose <br />SW 114 of the SW 11" <br />8. Proposed Well Driller License o tional : <br />swore <br />Toonatvp <br />Nors I <br />Range <br />Ear W <br />Pdmpd Meridian <br />10. Name of Well Owner or Authorized Agent <br />25 <br />47 <br />I <br />16 <br />New Mexico <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 />Distant a wd sere aecbon Ones (sadron Oren are typically not propertr knes) <br />thereof and state that they are true to my knoy0ed e. <br />762 Ft N m(. N V,! S 56 Ft rrom r E IT W <br />stun or two <br />Dare (mrr wflyyvl <br />S •_i3 <br />For replaamad walla arty — OMance and dnedlon from old we" to now wall <br />feet direction <br />If sWmg print name. Print rift it omen than land owrw. <br />Kee+ <br />C ke.� , p _ , _ _ 60"40+ � <br />`Office <br />Wall laodat address prattdo Qty, Steta, Zip) Check a wee address Is same as Ilam 1 <br />2600 and AA Road, Nucia, CO 81424 <br />Use Only <br />Opdbnal: GPS well locatlon lnfwmatlon in UTM format <br />Was map name <br />0" map no <br />surface dev <br />You must d" GPS unit fa required aalkW as folows: <br />Format wto be UrM <br />n zone 12 or 17 zone 13 <br />units must a Melon <br />l rep <br />Lai <br />Receipt area only <br />Datum nod be NAD83 <br />Northing <br />A P <br />unn nwd be ad to true north <br />Remelttber h/ set Datum to NAD83 <br />f <br />Was GPS unit dtadud for aborel []YES <br />N Vj <br />5. Property Owner Information <br />N" of property omaa <br />Garvey &Co., LLC <br />Tr <br />ssactiontlr: 3660054 <br />tAdtaq adA.p ' <br />P.O. Box <br />Transaction Tots], $300.00 <br />cay <br />state <br />Zip Code <br />Nucla <br />CO <br />81424 <br />CREDIT CARD $300.00 <br />Telephone e <br />DIV_ WD_ BA_ MD <br />790 864 -2243 <br />