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

(:ULORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER CO 80203
Phone: [phone] Fax: [phone] dwmermitsonlinegstatf
MONITORING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be typed, completed online or in black or blue ink.
1. Well Owner Information
Name of well owner
Williams Fork Land Company
Mailing address
PO Box 187
Craig ICO 181626
'970) 824-4401
2. Type Of Appli(
® Use existing well
❑ Construct new well
❑ Other:
3. Refer To (if air
Office Use Only
Form GWS -46 (11/2011)
6. Use Of Well
Use of this well is limited to monitoring water levels
and/or water quality sampling
7. Well Data (proposed)
27 feet Un -named
8. Consultant Information (if applicable)
Name of contact person
on (check applicable boxes)
❑ Replacement for existing monitoring well: Company name
Permit no.:
Mailing address
le)
I wets name or m
MH- 53050 GLEV-2
4. Location Of Proposed Well Im ortantl See Instructions'
County
offat NW 1/4 of the NW 1/4
Section Township N or S Range E or W PnncipaI Mardian
33 6 f7 [ 90 r PC] 6th
Distance of well from section Imes (section lines are typically not property lines)
227 Ft. from(? N [ S 1262 Ft from h E PK W
For replacement wells only— distance and direction from old well to new well
feet direction
Well location address (include City, State, Zip) N Check if well address is same as Item 1
Optional: GPS well location information in UTM format
You must check GPS unit for required settings as follows:
City I State I
Zip Code
Telephone #
9. Proposed Well Driller License #(optional)•
10. Name of Well Owner or Authorized Agent
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.
24-4-104 (13xa). I have read the statements herein, know the contents
thereof and state that they are true tom knowled e.
Sign or enter full name here Date (mMdd/yyy
Graham Roberts 01/15/201E
If
Iff signing pnnt name. Pnnntt title if other than land owner.
Office Use Only
USGS map name DWR map no. Surface elev
Format must be UTM
i Zone 12 or f• Zone 13 Easting 287932P
Recei t area
Units must be Meters
Datum must be NAD83 Northing 4479604
Unit must be set to true north
Remember to set Datum to NAD83
Was GPS unit checked for above? a YES
5. Property Owner Information
Name of property owner
Williams Fork Land Company
Mailing address
PO Box 187
State Zip Code
aig CO 181626
Telephone #
[phone]
DIV_ WD_ BA_ MD