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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(1112011) <br /> DEPARTMENT OF NATURAL RESOURCES <br /> 1313 SHERMAN ST.,Ste 821,DENVER CO 80203 RECEIVED <br /> Phone: 303 866-3581 Fax: 303 866-2223 dwr ernlitsonline state.co.us <br /> MONITORING/OBSERVATION AUG 0 5 2014 <br /> Water Well Permit Application <br /> Review instructions on reverse side prior to completing form. WATER RtaUURC:ts <br /> The form must be typed,completed online or in black or blue ink. STATE ENGINEER <br /> COLD. <br /> 1.Well Owner Information <br /> Name of well owner 6. Use Of Well <br /> Union Milling Company, LLC Use of this well is limited to monitoring water levels <br /> Mailing address and/or water quality sampling <br /> P.O. Box 620490 7.Well Data (proposed) <br /> City State Zip code Total depth Aquifer <br /> Littleton CO 80162 <br /> 100 feet Glacial Fill <br /> Telephone# E-Mad(If filing online A is required) 8. Consultant Information (if applicable) <br /> 303-947-7837 hmichael@unionmilling.com Name of contact person <br /> 2. Type Of Application (check applicable boxes) <br /> [IUse existing well ❑Replacement for existing monitoring well: Company norm <br /> ®Construct new well Permit no.: <br /> ❑Other: Mailing address <br /> 3. Refer To (if applicable) <br /> Momtonng hole acknowledgment W ell name or# City State Zip Code <br /> M H- <br /> 4. Location Of Proposed Well Im ortantl See Instructions Telephone# <br /> County <br /> Lake 1/4 of the v4 9. Proposed Well Driller License# o tional : <br /> Section Township I Nor S Range E or W Principal Mendkan 10. Name of Well Owner or Authorized Agent <br /> r— Ix r r The making of false statements herein constitutes perjury in the second <br /> 33 9 80 6th degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br /> 24-4-104(13)(a). I have read the statements herein,know the contents <br /> Distance of well from section Imes(section lines are typically not property lines) thereof and state that they are true to my knowled e. <br /> Ft.from F_ N t_S Ft.from r- E r W Sign or enter full name here Date(rrvrWdlyyyy) <br /> For replacement wells onty—distance and direction from old wen to new well Holly Michael, Member 08/04/2014 <br /> feet direction H signing print name. Print title if other than land owner <br /> Well location address(Indude City.Stale,Zip) 0 Check if well address is same as Item 1 <br /> 13815 Highway 24, Leadville CO 80461 Office Use Only <br /> Optional: GPS well location information in UTM format <br /> You must check GPS unlit for required settings as follows: USGS map name DW R map no. Surface elev. <br /> Format must be UTM <br /> [—Zone 12 or IT Zone 13 Easting 3 l S•WI m� Receipt area only <br /> Units must be Meters <br /> Datum must be NAD$3 Northing <br /> .Unit must be set to true norm vv, A E 33—9 S— go <br /> V� <br /> Remember to set Datum to NAD83 F: 3 8-189�' N <br /> Was GPS unit checked for above? ❑YES N , at�y Sot?:.y g$q' r1 SL., 1 333"SS L_ <br /> 5. Property Owner Information <br /> Name of property owner <br /> Constructive Investments, LLC <br /> Tra •,ac(ion#: 3666028 <br /> Mailing address fJ0 �rfl.35 AM <br /> P.O. Box 620490 .. )00 <br /> City State Zip Corte <br /> Littleton CO 180162 <br /> Telephone# 4 <br /> DN_ W D � BA MD _ <br /> 303-947-7837 <br />