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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(1112011) <br /> DEPARTMENT OF NATURAL RESOURCES ) <br /> 1313 SHERMAN ST.,Ste 821,DENVER CO 80203 <br /> Phone: 303 866-3581 dwr ermitsonline state co us <br /> MONITORING/OBSERVATION E <br /> Water Well Permit Application <br /> Review instructions on reverse side prior to completing form. �. <br /> The form must be typed,completed online or in black or blue ink. <br /> 1.Well Owner Information <br /> Nacre of well owner 6. Use Of Well <br /> Transit Mix Concrete Co. Use of this well is limited to monitoring water levels <br /> Meiling address and/or water quality sampling <br /> 444 E. Costflla St. 7.Well Data(proposed) _ __ <br /> City State Zip tale Total depth --- _. 4Coiter <br /> Colorado Springs CO 80903 <br /> 103 feet I Granite <br /> Telephone# E-Mail tlf filing online it is retlu,,ed: 8.Consultant Information (if applicable) <br /> (719)475-0700 Jerald.Schnabel@Transitmix.co Name or contactpersai <br /> 2.Type Of Application (check applicable boxes) Mike Day <br /> E)Use existing well ❑Replacement for existing monitoring well Company name <br /> E Construct new well Permit no Hydro-Logic Solutions, Inc. <br /> ❑Other 56847-M H Mathng address <br /> 3.Refer To(if applicable) 6100 Montview Blvd <br /> Monitoring hole acknowiedgment Well name or# Oty state Zip Code <br /> MH- 56847 LTC-GW-2 Denver CO 180207 <br /> 4. Location Of Proposed Well Ion ortantl See Instructions Telephone a <br /> County (303)570-9527 <br /> El Paso NW 114 of the NW t'4 9. Proposed Well Driller License#(optional): <br /> sect.ai, Township N or s Range E o,Vt' Principal Me•d,an 10. Name of Well Owner or Authorized Agent <br /> ii x The making of false statements herein constitutes perjury in the second <br /> 16 16 67 6 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 /> D•stance of wen from sector lines(sector lines are tvpica+ly nol vopert lines thereof and state that they are true to my knowledge <br /> Ft fromr N S Ft from E W Sign or enter full name here Date(mrNdd'yy", <br /> For reptacemem wells only-distance and direction'-om old wall to new well Jerald Sehnabel 10/12/2017 <br /> feet direction n s g—g print name P—'brie,'other than land owner <br /> well iocabon address(mGude City,State,Zip, 11"neck A well address t same as he,1 President,Transit Mix Concrete Co, <br /> 2485 Hitch Rack Ranch Rd. Colorado Springs, CO 80926 Office Use Only <br /> Optional: GPS well location information in t:TM format <br /> You must check GPS unfit for required settings as follows USGS mar,name DW'N map no Surraca Ole, <br /> rornat must be UTM <br /> Zone 12 or.Zone 13 Easung 509856 Receipt area only <br /> Units most be Meters <br /> Datum must be NAD83 Northing 4278527 <br /> Unit must be set tc"north <br /> Remember to set Datum to NAD83 <br /> Was GPS unit checked for aliove" ®YES <br /> 5. Property Owner Information <br /> Name of property avnef <br /> RMBC Group, LLC <br /> Malting address <br /> 712 Kris Ct. <br /> City State Lp code <br /> Los Alamos NM 187544 <br /> Telephone C <br /> Div____ wD �� BA MD <br />