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(01/2020)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,Ste 821,DENVER CO 80203
Phone: [phone] dwr ermitspnline state.co.us RCVD DWR
MONITORINGIOBSERVATION
Water Well Permit Application
Review instructions on ,reverse side prior in to In black
o farm. 09/23/2020
The form must he typed,completed online ar In 6Eack ar klue ink.
1. Well Owner Information
Name of we4 owner 6. Use Of Well
Trapper Mining Inc. Use of this well is limited to monitoring water levels
Mailing address and/or water quality sampling
PO Box 187 7.Well Data (proposed)
Aquifer
A
City State Zip code Total depth q
Craig CO 81626 285 feet Un-Named
Telephone# E-Mail(it flling online itisrequired) 8. Consultant Information (if applicable)
970-826-6143 [e-mail] Name of contact person
2.Type Of Application (check applicable boxes)
N Use existing well ❑Replacement for existing monitoring well: company name
❑Construct new well Permit no.:
❑Other: Mailing address
3. Refer To (if applicable)
Monitoring halo acknowledgment Well name or# city State Zip Code
MH- 60895 CY-2
4. Location Of Proposed WeII Im ortantl See Instructions Telephone#
County
Moffat SW 114ofthe NW 114 9. proposed Well Driller License# optional
Section Township NorS Range EcrW PrincipalMeridian 10. Name of Well Owner or Authorized Agent
28 6 � ❑ 91 ❑ IE 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.
Distance of well from section lines{section lines are typically not property lines} 24-4-104(13ya). I have read the statements herein,know the contents
Ike thereof and state that the are true tom knowledge,
2518 Ft.frornTI N❑S 670 Ft.from❑ 0 E W sign or enter full name here Date(mmlddlyyyy)
For replacementwe%scniy—distanceanddirectlonfromoldwelltonewweli Graham Roberts 09/23/2020
feet direction It signing print name. Print title if other than land owner.
Welt location address(Include City,State,Zip) Checkifwell addressissame 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 or[k]Zone 13 Easting 278121 Receipt area only
Units must be Meters
Datum must be NAD83 Northing 4480855
Unit must be set to true north
Remember to set Datum to NAD83
Was GPS unit checked for above? W YES
5. Property Owner Information 10006468
Name of property owner I
State of Colorado Land Board
Mailing address
1127 Sherman Street, Suite 300
City State Zip Cade
Denver CO 80203
Telephone#
303-866-3454 DIV WD_ BA MD