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COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only Form OWS-46 (11/2011) <br />DEPARTMENT OF RESOURCES <br />RECEIVE <br />3 , 13 SHERMAN STt, DENVER CO 80203 <br />Phone: 303 8W3681 Fax 303 866-2223-tffimmitsodine0state <br />MONITORING /OBSERVATION <br />MAY 17 2013 <br />Water Well Permit Application <br />Review Instructions on reverse side prior to completing form. <br />-HATER RtSOURCE <br />STATE ENGINEER <br />The form must be typed, completed online or In black or blue Ink. <br />rn�, 0 <br />1. Well Owner Information <br />of wM Dona <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />Western Fuels Colorado, A Limitted Liability Company <br />and/or water quality sampling <br />Moarw.daroa <br />1100 W. 116th Avenue <br />7. Well Data (proposed) <br />CRY <br />Stets ZIP Code <br />Total doh <br />war <br />Westminster <br />CO 80234 <br />62 feet <br />Dakota Formation <br />E4"I (If fling wine Itisniqui <br />8. Consultant information (if applicable) <br />Norm of contad Qerson <br />Douglas C. White <br />303254 -3208 <br />mgsorensen@tdstategt.org <br />2. Type Of Application (check applicable boxes) <br />❑ Use existing well ❑ Replacement for existing monitoring well: <br />Cone°f v n"rB <br />■ Construct new well <br />Western Fuels Association, Inc. <br />Permit no.: <br />❑ Other. <br />Mining aadroea <br />12050 N. Pecos Street, Suite 100 <br />3. Refer To (if applicable) <br />MorYbrkq hole <br />VMnsmoorilli <br />City <br />Sims <br />Zip Cads <br />MH- <br />GW 58 <br />Westminster <br />CO <br />180234 <br />4. Location Of Proposed Well (Importantl See instructions <br />303 255 -5806 <br />cmdy <br />Montrose <br />SW 114 of the SW tr< <br />9. Pro ed Well Driller License # o tlonal : <br />section <br />Tonmlep <br />NorS <br />Range <br />Eorw <br />PnndpalMsddien <br />10. Name of Well Owner or Authorized Agent <br />25 <br />47 <br />R r' <br />I <br />16 <br />n n <br />I <br />New Mexico <br />I <br />making � Ise statements herein constitutes perjury In the second <br />degree, 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 />Distance of wall frwn secean nnae (secnan lines we typically not property wee) <br />thereof and state that they are true to my knowledge. <br />770 Ft nom[! N 19 S 56 Ft rrom C: � E IT. w <br />slyn none hero <br />Date (nmadryyyy) <br />For repacemorl wens only— distance and d rocnon from old wen 1A new well <br />feet direction <br />If signing pnnl nerve lit too If other Hen landowner <br />Cikats G_ _ r _ A �• (Q <br />wen 1-11,n addross (Iodide City. State, Zip) Check iTwen address is same ss torn 1 <br />2600 and AA Road, Nucla, CO 81424 <br />Office Use Only <br />Optlomal: GPs well' - i ", rt Information In UTM format <br />USES map name <br />DWR map no <br />swface slew. <br />You mud check GPs unit for required settings as Mows: <br />Formal meal to UTM <br />[J Zone 12 or n Zone 13 <br />Emoting <br />Receipt area only <br />UNts mot be Maters <br />catoe mot be NAM <br />Northing <br />Unit mot be ed to Inis north <br />Remember to sat Datum to NAD83 <br />S ±hI t W <br />was GPS urn ahecbd for abOW j] YE8 <br />f% fird w/o <br />IV OT <br />5. Property Owner Information . <br />Name of prop" owner <br />Garvey & Co., LLC <br />Morro aadrsas <br />P.O. Box 555 <br />Traimaction#-, <br />3660054t4, <br />Date: 5/178013 2:35:54 PM <br />Transaction Total, $300.00 <br />city <br />Sims <br />Zip Code <br />Nucla <br />CO <br />81424 <br />CREDIT CARD $300.00 <br />Tal.pl�r,e to <br />DIV _ WD— SA _ MD — <br />790 864 -2243 <br />