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
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER CO 80203
'hone: [phone] Fax: [phone] dwroermitsonlineta7stat(
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
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)
Craig ICO 181626 145 feet IUn-named
Telephone# E -Mail (If filing online it is required) 8. Consultant Information (if applicable)
[phone] Name of contact person
2. Type Of Application (check applicable boxes)
® Use existing well ❑ Replacement for existing monitoring well: Company name
❑ Construct new well
Permit no.:
❑ Other: Mailing address
3. Refer To (if aDDlicable)
monitoring nae acunomeagment Well name or #
MH- 53050 GLEV-3
4. Location Of Proposed Well Importantl See Instructions'
County
offat NW 1/4 of the NW 114
Section Township I N or S Range E or WFPnhnc4pal Meridian
33 6 n r! 90 n
Distance of well from section lines (section lines are typically not property lines)
227 FL from N [' S 1262 FL from ❑ E lxl w
For replacement wells only — distance and direction from old well to new well
feet direction
Well location address (Include City, State, Zip) 0 Check ifwell 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 State 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 to my knowledge,
Sign or enter full name here Date (mm/ddlyyy
Graham Roberts &Z 01/15/201
IIff/signing print name. Print title if other than landowner. L �y
Office Use Only '
USGS map name DWR map no. Surface elev.
Format must be UTM
C Zone 12 or I-- Zone 13 Easting 287935 Receipt area
Units must be Meters
Datum must be NAD83 Northing 4479605
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
StateZip Code
_ . aig CO 81626
Telephone #
[phone]
DIV_ WD_ BA_ MD