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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 astate co us <br /> MONITORING/OBSERVATION <br /> Water Well Permit Application <br /> t <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 or well owner 6. Use Of Wel <br /> Transit Mix Concrete Co. Use of this well is limited to monitoring water levels <br /> Mailing address and/or water quality sampling <br /> 444 E. Costilla St. 7.Well Data(proposed) <br /> City State Z;D cvca 'oral Crrpth <br /> Colorado Springs CO 80903 <br /> 203 feet Granite <br /> Telephone A TFCMai1 if filing ontne i;is regiired' 8. Consultant Information (if applicable) <br /> (719)475-0700 raid.Schnabel@Tra nsitmix.co oane of Cunkaci pe sy^ <br /> 2.Type Of Application (check applicable boxes) Mike Day <br /> Cornpam•Wane <br /> ❑Use existing well ❑Replacement for existing monitoring well <br /> *Construct new well Permit no Hydro-Logic Solutions, Inc. <br /> ❑other 56847-MH Ma,lag address <br /> 3. Refer To(if applicable) 6100 Montview Blvd <br /> Mondonng hake acknowledgment Well name or 9 City atelip Code <br /> MH- 56847 LTC-GW-4 Denver TCS17 80207 <br /> 4. Location Of Proposed Well Important! See Instructions) 'elephone Y <br /> County (303)570-9527 <br /> El Paso NW 'A of the NW t.4 9. Proposed Well Driller License#(optional). <br /> S;1for Township N nr S Range E or W Pnnc�pal Mendian 10. Name of Well Owner or Authorized Agent <br /> 16 x 67 ;it The <br /> The making of false statements herein constitutes perfury 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 reac the statements herein,know the Contents <br /> D�stance of well from sect or lanes,sector lines are iywcaty no:property lines) thereof and state that they are true to my knowledge <br /> Fi hcn,� N' S Ft from E w sign x enter full nan+e here Date l—VCld,ryyr.l <br /> For replacement wells only-distance and dveHiun f-on,old well to new well Jerald Schnabel 10/12/2017 <br /> feet direction if signing pni^,tame Pint Dlle;f othe,Man land owner <br /> Well location address(Include City state Lot Cj Check e wen address,s same as fieni i President, Transit Mix Concrete Co. <br /> 2485 Hitch Rack Ranch Rd. Colorado Springs, CO 80926 Office Use Only <br /> Optional GPS well location inforrnatior m UTM format <br /> You must check GPS unit for required settings as follows .JSGS map rame DWR rap no Surface elev <br /> Format rrklsl be JTM <br /> Zone 12 or- Zone 13 Easiing 509217 Receipt area only <br /> Units must be Meters <br /> Datum must be NAD83 Northing 4278795 <br /> Unit must be wl to true north <br /> Remember to set Datum to NA083 <br /> Was GPS inn checked for abo•.e° a YES <br /> 5. Property Owner Information <br /> Narne of property ownet <br /> RMBC Group. LLC <br /> Mailing address <br /> 712 Kris Ct, <br /> City IN <br /> tate Zip rode <br /> Los Alamos M 87544 <br /> Telephone a <br /> DN WD BA MD <br />