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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 a state.co is <br /> MONITORING/OBSERVATION <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 wait owner 6. Use Of Well <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 /> ---- — - ----- ----- ---- <br /> 'otal depth Aoude, <br /> City Stale Zip .de <br /> Colorado Springs CO 80903 <br /> 52.5 feet Granite <br /> Telephone# E-Mail fit Fling online it isiequired� 8. Consultant Information (if applicable) <br /> (719)475-0700 Jerald.Schnabel@Transitmix.co Name ur coWac'Wesor <br /> 2.Type Of Application (check applicable boxes) Mike Day <br /> ❑Use existing well ❑Replacement for existing monitoring well Company name <br /> ®Construct new well Permit no. Hydro-Logic Solutions, Inc. <br /> ❑other 56847-MH Va bng add ess <br /> 3. Refer To(if applicable) 6100 Montview Blvd <br /> Mon lonng hole acknowiedgmenl FL'TCG6 <br /> name��x City State Zip codeMH- 56847 - W- Denver CO 80207 <br /> I T <br /> 4. Location Of Proposed Well (important! See Instructions e�phxet <br /> cd,,ny (303)570-9527 <br /> El Paso NW •14 of!he NW 14 9, Proposed Well Driller License#(optional): <br /> Section Township N o•S Range F orw Pnn"lidl Meidian 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 /> Distance of well fror-section ones isernor bass are tvpicany no•wuper)Pnesi _ thereof and state that they are true to my knowledge <br /> FI from r— N S Fi i,om. E W Snr,a enter full meanie here Dal.(mmiftyyyY) <br /> For replacement welts only-distance and d+mdion from old well to new.mil Jerald Schnabel 10112/2017 <br /> feet direction i'signing po 1 came Print title if othe,,an lanC Cwner <br /> Well location address(hdude City Slate.Lp) L1 check t'well address is&ante as item, President, Transit Mix Concrete Co. <br /> 2485 Hitch Rack Ranch Rd.Colorado Springs, CO 80926 Office Use Only <br /> Optional. GPS web location information in UTM format <br /> You most check GPS un,i for requireC settings as follows USC 5 map^ar,e DWR map no Surface elev <br /> Format must be UTM <br /> Zone 12 or ti Zone 13 Easting 509911 Receipt area only <br /> Units mus:be Metes — <br /> Datum must be NAD83 Nonhmg 4278558 <br /> unit must be set le true north <br /> Remember to set Datum to NAD83 <br /> Was(BPS unit checked for above- a YFS <br /> 5. Property Owner Information <br /> Name of property owner <br /> RMBC Group, LLC r- <br /> Mailing address •+ <br /> 712 Kris Ct ' <br /> City state k7544 <br /> ir Code <br /> Los Alamos NM <br /> Telephone k <br /> DIV WD 10 BA^ MD <br />