2021-02-08_PERMIT FILE - M2021009 ‎(10)‎

• Permit No: M2021009
• IBM Index Class Name: PERMIT FILE
• Doc Date: 2/8/2021
• Doc Name Note: Part 3 of 3
• Doc Name: Application
• From: Young Ranch Resource LLC
• To: DRMS
• Email Name: AME
• Email Name: MAC
• Email Name: AWA
• Media Type: D
• Archive: No

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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(0712009)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST,RM 818,DENVER,CO 80203
phone-info:[phone] main: [phone] RECEIVED
fax: [phone] http:/1www.water.state.co.us
GENERAL PURPOSE APR 16 2012
Water Well Permit Application y�q�ER EE
Review Instructions on reverse side prior to completing form. 3TATEC �>�1�R5
The form must be completed In black or blue Ink or typed.
1.Applicant Information S._Use Of WellLcheck applicable boxes)
Name of appkrxe Attach a detailed description of uses applied for.
City of Black Hawk ❑Industrial ❑Dewatering System
1110%address ----.____._.__-__- -- 0 Municipal ❑Geothermal(❑production or❑reinjection)
P.O. BOX 68 ❑Irrigation
— _-----—.__.—.-----._._— ❑Other(describe):
city Black Hawk stale
7
Co ; 'o`�e80422 .Well Data(proposed)
Commercial
Telephone Is - -meil j6plomap ---- -- Well
303-582-1324 [e-mail] Mafdmun+PunrIng rate— .__.__. -Annual�M to be wthaaiin --
2.Type Of Application (check applicable boxes) 800..._—__•____-_. sam , 1291
acre-feet
❑ Construct newwett ❑Change source(aquifer) 5-4 Aug A��UVIa�
[I Replace existing well ❑Reapplication(expired permit) feet
0 Use existing well ❑COGCC well 8.Land On Which Ground Water Will Be Used
❑Change or increase use ❑Other. Legal Description(may be provided as an attachment):
3.Refer To(if applicable)_ Within Black Hawk Municipal Service Area,
VJeu pamiit a<_ — i YVeier Coiri case A �_. __._._ _ __— ...__ P
287498 _ generally located in Section 7, T.3S., R. 72 W. of
ossigleted Resin deii �etior — — Wei Acme or r
Hidden Valley Infiltration Gallery the 6th PM
i
4.Location Of Proposed Well(Important!See Instructions) (K used for crop irtipation,attach a salad map that shows Irrigated area,)
cry
Clear Creek i SE 1m ortne NE 114 A. eAoes N/A 1 B. r*~N/A
2 - O � any - -0�6th - c w��t��W�s'9 a rights r,��w
Secbar+3L TarrtuhP N w S R E a W Pt4wPel Maddan
❑ ✓ 72 ❑ this land
__.._ _ 40.94CWOW.5311-F-R,/ebe&F.411W.48675-F
Distance d wd from section a(section lines are not property Gros)
2313 Ft,"m M N❑s 1229 FL N-0 E❑W 9.Proposed Well Driller License tiona( :
For replacement wags My-distance and direction old wag tonew wag- 10.Signature OfApplicant(s)Or Authorized Agent
feet direction --
___ _ _..------.-----— The making of false statements herein constitutes perjury in the second
Wee location address(Include City.State.Zipl t_I Check it vras address s same as in Item 1. degree,which Is punishable as a class 1 misdemeanor pursuant to C.R.S.
2189 Idaho Springs Rd. East, Idaho Springs, CO 80452 24-4-1U4(13)(a). I have read the statements herein know the contents
p 9Sthereof and state that they are true t m edge.
_ .-. ----_--- Sign here!Hoa r bs orlpete7 signetwe - /--- - Data
Optiotlalk GPS well location information in UTM format You must check GPS unit for Cf/
required settings as Wows. (Z 44?q Z
-
Formal nett be llTIA P4'IM name a .
0 Zone 12 or 0 Zone 13 Easting ames R. Ford, Water System Coordinator
Units must be Waters
Datum must be NADe3 Office Use Only
Northing
u.t must be set to true narm tiSGS map name DWR map no. Surfeoa etev.
Was GPS�xvt othed m for above9 ❑YES Remember to set Datum to NAD83
S. Parcel On Which Well Will Be Located Receipt
pt area only
(YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) (Dry ✓
A. Legal Description(may he provided at an auaaunenq.See attached
EXHIBIT A
I
8. #or actas in parcel- C. owner AQUAMAP Tri�nslcitionn -365+t$41
1.88 City of Black Hawk ,,,,E r;}42- 4fj6n012 9 5618 ANI
D. ww this be tM any wall«,ewe paroel7❑vEs�J NO(it no-hot o8her wets) - wR 4.11911 Total: 310 0.00
310 0.00
056847 F cwce
TOPO
State Parcel We(oltonel)
MYtAR
S85 DIV_ WD L_ 13A_�_ MD