Laserfiche WebLink
COLORADO DIMON OF WASTER RESOURCE Office Use Only Form GWS46(05/2011) <br /> DEPARTMENT OF NATURAL RESOURCES E9 <br /> 1313 SHERMAN ST.,ROOM 1111211,DENVER CO 80203 <br /> Main: 88e-3581 Fax=O 3589 <br /> MONITORINGIOBSERVATION DEC 10 2012 <br /> Water Well Permit Application ,HATER RESOuRCEs <br /> Revlsw Ineftatione on reverse aide prior to comp�ing form. STATE EN I14EFR <br /> Tire form most be completed Inblack or blue Ink or lyped. COL <br /> 1.Weil Owner htfonlnation <br /> Nano orwd anser S.Use Of Well <br /> Cotter Corporation (N.S.L.) Use of this well Is limited to monitoring water levels <br /> and/orwater quality sampling <br /> Mdtne aamsss <br /> 7800 E Dorado Place, Suite 210 7.Well Data(proposed) <br /> ` soft zo 239.9 letrt NO a <br /> CRYesleneW(PrwAmbr;an) <br /> Englewood Co 80111 <br /> Telephaof 8.Consultant Infannatlon(if applicable) <br /> q20)554-8211 Nave dw nact I <br /> Susan Wyman <br /> 2.Type Of Application(check applicable boxes) <br /> c patty rare <br /> b use elb*vwell CST Replacement for"Ong g monitoring wet Whetstone Associates, Inc. <br /> ®Construct now well Parrnit no.: <br /> Nal <br /> C10tltm: rnp aa�eee 104 W. Ruby Avenue <br /> 3.Rder To(If applicable) „ zip code <br /> Mort No��1 cq <br /> MH-50969,/ MW18 Gunnison CO 81230 <br /> T.tepharo n <br /> 4.Location Of Proposed Well QnVortantl Sae Inatructlorw (970)641-7471 <br /> Jefferson NW imaty. SE ,m 9.Pro used Well Driller License al <br /> senor NarS ar , �, 10.Signire Of Well Owner Or Authorized Agent <br /> The msW%of false statements herein constitutes perlary In the second <br /> 25 2 1ST® 71 ❑® 6th decree,which Is punishable as a class 1 mlademeanor pursuant to C.R.S. <br /> 24-4-104(13)(s). 1 have read the statements herelr%know the contents <br /> DIeta>re atwetl Mom sedan Ones <br /> (sedan ms as trpiodEy not propatq Nrss) thereof and state that are true t0 Mowied e. <br /> 1,730 Ft ftm 13 N®S 1,820 FL from 10 E❑w {'*iA1 be Nam) <br /> For repiacemamt a adl—a�evne aw tAredort from on wail to Crow weo / <br /> feet direction "a11e s e1e <br /> war Taman sows(edws cry.Stern.zip) LiChMitlWaffaftesalesurnenront �AgF <br /> 8300 Glencoe Valley Road,Golden,CO 80402 Office Use Only <br /> Optin al: GPS well locelkm Irfiormellon In UTM ronnet Lew map nwe MR trap no. Swfsce dev. <br /> You must cheek GPS unit for required settbtgs se fallwn: <br /> Formes mist be UTM <br /> I- <br /> 0 zone 12or0 Zarat3 EesUng Receipt area only <br /> unft must be!Asters <br /> Dshtm rant be NAM <br /> Notating <br /> U19 muat be ed to hue roM <br /> was clay welt d**W nor 0*w? OYES Rwmwber to act PAM to NMN <br /> 5.Property Owner Infonnatlon <br /> Name al prawty owner <br /> Cotter Corporation (N.S.L.) <br /> tAadlingaWdraee rttrtsactwgno: 3058027 f <br /> 7800 E Dorado Place, Suite 210 e: 121Torzo112 s:aa:at AN <br /> ae siftspc� Cl ECK03578; $800.d#1 <br /> Englewood Co 80111 <br /> Tdep rdeti <br /> (720)554-6211 oN_L wn—�L ea_ MD— <br />