2020-12-21_PERMIT FILE - C1981010 ‎(17)‎

• Permit No: C1981010
• IBM Index Class Name: Permit File
• Doc Date: 12/21/2020
• Doc Name: Design & Construction for GW Monitoring Wells
• Section_Exhibit Name: APPENDIX V PART C
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(0112020)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,Ste 821,DENVER CO 80203
Phone: [phone] dwr ermitsortline state.co.us RCVD
DWR
MONITORING/OBSERVATION
Water Well Permit Application Review instructions on reverse side prior to completing form. 09/23/2020
The form must be typed,completed onlineine or In black or blue ink.
1.Well Owner Information
Name of well owner 6. Use Of Well
Trapper Mining Inc. Use of this well is limited to monitoring water levels
Mailing address andlor water quality sampling
PO Box 187 7.Well Data (proposed)
City Stale Zip code
Total depth Aquifer
Craig CO 81626
165 feet Un-Named
Telephone E-Mail(If filing online it Is required) 8. Consultant Information (if applicable)
970-826-6143 [e-mail] Name of contact persan
2.Type Of Application (check applicable boxes)
0 Use existing well ❑ Replacement for existing monitoring well: Company name
❑Construct new well Permit no.:
❑Other: Mailing address
3. Refer To (if applicable)
Monitoring hole acknowledgment Well name or# city Stale Zip Code
MH- 60895 CY-1
4. Location Of Proposed Well (important! See Instructions Telephone#
County
Moffat SW 114ofthe NW 114 9, Proposed Well Driller License# optional :
Section Township I N or S Range E or W Principal Meridian 10. Name of Well Owner or Authorized Agent
28 6 Q ❑ 91 ❑ r 6th The making of false statements herein constitutes perjury in the second
degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
244-104(13)(a). I have read the statements herein,know the contents
Distance of well from section lines(section lines are typically not property lines) thereof and state that they are true to my knowledge,
2518 Ft.fromg N❑S 670 Ft.from❑ E 9 W Sign or enter full name here Date(mmlddlyyyy)
For replacement wolls only—distance and direction from old well to new well Graham Roberts 09/23/2020
feet direction If signing print name. Print fills if other than land owner.
Well location address(Include City,State,Zip) ❑check if well address is same as Item 1. Graham Roberts, Environmental Eng.Trapper Mining Inc.
6.5 Miles SW Craig CO Office Use Only
Optional: GPS well location information In UTM format
You must check GPS unit for required settings as follows: USGS map name DWR map no. surface elev.
Format must be UTM
❑Zone 12 or0w Zone 13 Basting 278124 Receipt area only
Units must be Meters
Datum must be NAD83 Northing 4480852
Unit must be set to true north
Was GPS unit checked for above? 11 YES
Remember to set Datum to NAD83 10006471
5. Property Owner Information
Name of property owner
State of Colorado Land Board
Mailing address
1127 Sherman Street, Suite 300
City State Zip Code
Denver CO 80203
Telephone#
DIV Wb BA MD
303-866�3454