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r R <br /> COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(11/2011) <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 ermitsonline state.co.us <br /> MONITORING/OBSERVATION AUG 0 5 2014 <br /> Water Well Permit Application WATER REaUURI..L:- <br /> Review instructions on reverse side prior to completing form. STATE ENGINEER <br /> The form must be typed,completed online or in black or blue ink. COLO <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 100 feet Glacial Fill <br /> Telephone# E-Mail(if filing orgineitisrequired) 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 /> ❑Use existing well ❑Replacement for existing monitoring well: Company name <br /> 0 Construct new well Permit no.: <br /> 0 Other. Mailing address <br /> 3. Refer To (if applicable) <br /> Monitortrg hole acknowledgment Well name or# City State Zip Code <br /> MH- <br /> 4. Location Of Proposed Well Im ortantl See Instructions) Telephone# <br /> County <br /> Lake 114 0(the 114 9. Proposed Well Driller License# o tional : <br /> Section Township N or S Range E w W I Principal Meridian 10. Name of Well Owner or Authorized Agent <br /> F— r r IX The making of false statements herein constitutes perjury in the second <br /> 28 9 80 6th degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br /> 244-104(13)(a). I have read the statements herein,know the contents <br /> Distance of well from section Imes(section lines are typicaNy not property lines) thereof and state that they are true to my knowledge. <br /> Ft.ft.r— N 1 S Ft from I—E h W Sign or enter full name here Date(mmlddlyyyy) <br /> For replacement wells orgy—distance and direction from old well to new well Holly Michael, Member 08/04/2014 <br /> feet direction If signing print name. Print title if other than land owner. <br /> Well location address(Include City.State,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 unit for required settings as follows: USGS map name 75_w� <br /> Surface elev <br /> Format must be UTM <br /> f^Zone 12 or r Zone 13 Eastin Receipt area only <br /> Units moat be Meters <br /> g 31' 13• -1-1 q <br /> Datum must be NAD83 Northing —t p 6 I cl S <br /> Unit must be set to true north <br /> - Remember to sat Datum to NAD83 <br /> Was GPS unit checked for above? I_1t YES E . 3 6 s o 6 6 $ 1 <br /> 5. Property Owner Information N- 4313-.03 $ 7-08' S SL) -7q 1 Est- <br /> Name of property owner <br /> Constructive Investments, LLC <br /> T n,artlnn 3E;ti6028� <br /> Mailing address D try: fiF42014 9:%3Ft AM <br /> P.O. Box 620490 <br /> t.RFnn cARD 3200.X <br /> City State Zip Code <br /> Littleton CO 80162 <br /> Telephone# <br /> DIV L_WD ' BA_ MD <br /> 303-947-7837 <br />