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UULORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., Ste 821, DENVER CO 80203 <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 well owner <br />Williams Fork Land Company <br />PO Box 187 <br />Craig ICO 181626 <br />(970) 824-4401 <br />2. Type Of Application (check applicable boxes) <br />® Use existing well ❑ Replacement for existing monitoring well: <br />❑ Construct new well <br />Permit no.: <br />❑ Other: <br />3. Refer To (if applicable) <br />murmuring none acKnowweagment Well name or # <br />MH- 53050 GLEV-1 <br />4. Location Of Proposed Well (Important! See Instructions) <br />IOffat NW 1/4 of the NW 1/4 <br />SeclJon Township N or S Range I E or W FP6ncipal Mendian <br />33 6 r f 90 r n <br />Distance of well from section lines (section lines are typically not property lines) <br />Ft froml� N r- <br />227 S 1262 Ft from r E r W <br />For replacement wells only— distance and direction from old well to new well <br />feet direction <br />Well location address (Include City, State, Zip) E Check if well address Is same as Item 1 <br />Optional: GPS well location information in UTM format <br />You must check GPS unit for required settings as follows: <br />Format must be UTM <br />F1 Zone 12 or R" Zone 13 Easting 287933 <br />Units must be Meters <br />Datum must be NAD83 Northing 4479607 <br />Unit must be set to true north <br />Remember to set Datum to NAD83 <br />Was GPS unit checked for above? XYES <br />5. Property Owner Information <br />Name of property owner <br />Williams Fork Land Company <br />Mailing address <br />PO Box 187 <br />.ty Slate Zip Code <br />_raig CO 181626 <br />Telephone # <br />(970) 824-4401 <br />Use <br />Form GWS -46 (11/2011) <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />and/or water quality sampling <br />7. Well Data (proposed) <br />238 feet Un -named <br />8. Consultant Information (if applicable) <br />Name of contact person <br />Company name <br />Mailing address <br />City <br />Telephone # <br />State I Zip Code <br />9. Proposed Well Driller License #(optional): <br />10. Name of Well Owner or Authorized Agent <br />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 />24-4-104 (13Xa). I have read the statements herein, know the contents <br />thereof and state that they are true to my knowledge. <br />Signor enter full name here Date (mnyddryyy! <br />Graham Roberts 01/15/201E <br />If signing print name. Pnnt bus if other than land owner. <br />Office Use Only <br />USGS map name DWR map no. Surface elev. <br />Receipt area <br />DIV_ WD_ BA_ MD <br />