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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(11/2011) <br /> DEPARTMENT OF NATURAL RESOURCES _ <br /> 1313 SHERMAN ST.,Ste 821,DENVER CO 80203 <br /> Phone: 303 866-3581 dwr ermttsonlineastate co us <br /> MONITORING/OBSERVATION 4 <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 /> Name of welt owner 6. Use Of Well <br /> Transit Mix Concrete Cc Use of this well is limited to monitoring water levels <br /> MadiN address and/or water quality sampling <br /> 444 E. Costilla St. 7.Well Data(_proposed) <br /> City slate Z p code Total depth _ Aou ter <br /> Colorado Springs CO 80903 <br /> 202 feet i Granite <br /> Telephoners E-Mailu`flrngonine,tistewireb, 8. Consultant Information (if applicable) <br /> (719)475-0700 Jerald.Schnabel@Transitmixco "anxao'Contact pers.,n <br /> 2.Type Of Application (check applicable boxes) Mike Day <br /> ❑Use existing well ❑Replacement for existing monitoring well- Cornpan,name <br /> N Construct new well Permit no. Hydro-Logic Solutions, Inc. <br /> ❑Other 56847-MH Mailing address <br /> 3.Refer To(if applicable) 6100 Montvlew Blvd <br /> frlonaonng hole aeknowledgrnent Weft name or a City Slate Zip code <br /> MH- 56847 LTC-GW-3 Denver CO 80207 <br /> 4. Location Of Proposed Well (Important! See Instructions Talephu"e a <br /> County (303)570-9527 <br /> El Paso NW 1,4 of rie NW 14 9. Proposed Well Driller License#(optional): <br /> Secttor Township N or S Range E o•W Principal Mer than 10. Name of Well Owner or Authorized Agent <br /> X 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 /> Distance o'wal,from sectton lines tsection lines we typically not oropeny IMe; thereof and state that they are true to my knowledge <br /> Ft fmmr N 1 S Ft 'ro, E W Sig"of enle'lull name tiere Date irvNdd.'yyyyl <br /> For replacement wells only-distance and director from old web to nen well Jerald Sehnabel 10/12/2017 <br /> feet direction It s'grm^y or nit norm Print title if other than land owner <br /> Well locallor,address(Include City,State rip) Cneck it wen address s sdr.,e as t:em, President. Transit Mix Concrete Co. <br /> 2485 Hitch Rack Ranch Rd. Colorado Springs, CO 80926 Office Use Only <br /> Optional: GPS well location information to UTM format <br /> You must check GPS unit for required settings as follows L.SCS map name DWR map nc Surface Ole, <br /> Formal must be UTM <br /> Zone 12 or zone 13 Easting 508816 Receipt area only <br /> Jnds most be Meters <br /> Datum must be NAD63 Northing 4278868 n <br /> Urn must be set to true non- <br /> Remember to set Datum to NAD83 <br /> Was GPS unit cnocxed for above? a YFS <br /> 5. Property Owner Information <br /> Name of property owner <br /> RMBC Group, LLC L <br /> Manmg address I* <br /> � I , <br /> 712 Kris Ct. <br /> City state Zip Code <br /> Los Alamos NM 87544 <br /> Teleptlorle a <br /> DIV__ WD ,0 BA_v_ MD <br />