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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(07/2013) <br /> DEPARTMENT OF NATURAL RESOURCES <br /> 1313 SHERMAN ST, RM 821,DENVER,CO 80203 <br /> Main.(303)866-3581 _.. <br /> GENERAL PURPOSE • <br /> Water Well Permit Application <br /> Review instructions on reverse side prior to completing form. <br /> The form must be computer generated,typed or in black or blue ink. <br /> 1. Applicant Information 6. Use Of Well(check applicable boxes) <br /> Name of applicant <br /> Attach a detailed description of uses applied for. <br /> Frances Barnett Lewis Trust ® Industrial ❑ Dewatering System <br /> Mail,ng address ❑ Municipal ❑ Geothermal(production or reinjection <br /> 608 North Vernal Avenue D Irrigation <br /> City State Zip code 0 Other(describe) _ <br /> Vernal UT 84078 ❑ Commercial <br /> Telephone#(area code 8 number) E-mail(online filing required) 7.Well Data(proposed) <br /> 970-629-5677 fmbllewis@yahoo.com Maximum pumping rate Annual amount to he withdrawn <br /> 2.Type Of Application(check applicable boxes) 15 gpm 1 acre-feet <br /> ❑Construct new well ® Use existing well <br /> Total depth Aquifer <br /> El Replace existing well ® Change or increase use 300 feet Alluvium&Sandstone <br /> El Change source(aquifer) 0 Reapplication(expired permit) 8. Land On Which Ground Water Will Be Used <br /> ❑ COGCC Well ❑ Other: Legal Description of Land(may be provided as an attachment) <br /> 3. Refer To (if applicable) <br /> Well permit P Water Court,.ase# <br /> 126165 N/A See Attached Warranty Deed <br /> Designated Basin Determinaton# Well name or# <br /> 6 Lot 50 Well <br /> 4. Location Of Proposed Well <br /> County (If used for crop irrigation,attach a scaled map that shows irrigated area.) <br /> Moffatt SE 1/4 of the NE 114 A. #Acres B. Owner <br /> Section Township Nor S Range E or W Principal Meridian <br /> 35 4 X I 101 ❑ 0 6th C. List any other wells or water rights used on this land <br /> Distance of wet from section lines(section tines are typically not property tines) N/A <br /> ,,r'p ' -1-958'is Ft from X N S '"q.14.-7 C ii }'6,,e Ft fronfilE flW <br /> For replacement wells only—distance and direction from old well to new well9. Proposed Well Driller License#(optional): <br /> feet direction 10. Sign or Entered Name Of Applicant(s)Or Authorized Agent <br /> Well location address(Include City,State,Zip) ❑Check if well address is sante as in Item 1 The making of false statements herein constitutes perjury in the second <br /> degree.which is punishable as a class 1 misdemeanor pursuant to C.R S. <br /> Lot 50, Skull Creek, CO, 81610 24-4-104(13)(a). I have read the statements herein,know the contents <br /> thereof and state that they are true to my knowledge. <br /> Optional: GPS well location information in UTM format You must check GPS unit for Sign or este,names)of person(si submitting application Date(mmrddiyyyy) <br /> required settings as follows <br /> Format must be UTM if signing print name and title <br /> !Zone 12 x[ ]Zore 13 Fasting <br /> Units must be Meters -- <br /> Datum must be NADB3 Northing Office Use Only <br /> Unit must be set to true north USGS map name DWR map no Surface elev <br /> Was GPS unit checked for above,DYES Remember to set Datum to NAD83 <br /> 5. Parcel On Which Well Will Be Located Receipt area only <br /> (PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) <br /> A. Legal Description may be provided as an attachment) 1 <br /> See Attached Warranty Deed •}) I > > I; <br /> ' <br /> AQUAMAP <br /> B. 4 of acres in parcel C. Owner <br /> WE <br /> 35.9 plus or minus Frances Lewis WR <br /> D. Will this be the only well art tors parcel, o YES NO(if no list other wells) Cly GB <br /> TOPO <br /> E. State Parcel ID#,optional) MVI AR <br /> 5B5 DIV WD BA MD <br />