Laserfiche WebLink
DocuSign Envelope ID:6BC32598-B737-464E-898A-81 F1 F7131339133 <br /> OMB No.2040-0042 Approval Expires 4/30/2022 <br /> United States Environmental Protection Agency iz Use Only <br /> Underground Injection Control Date <br /> .�. EPA Permit Application for a Class V Well <br /> (Collected under the authority of the Safe Drinking Water Act. Permit Number <br /> Sections 1421, 1422,and 40 CFR Part 144) <br /> Read Attached Instructions Before Starting <br /> I.Owner Name,Address,Phone Number and/or Email II.Operator Name,Address,Phone Number and/or Email <br /> Colowyo Coal Company,L.P. Same as owner <br /> P.O.Box 33695 <br /> Denver,CO 80233-0695 <br /> Barbara A.Walz,Senior Vice President,Policy&Compliance/CCO <br /> 303-452-6111,bwalz@tristategt.org <br /> III. Commercial Facility IV.Ownership V. Permit Action Requested VI. SIC Code(s) dian Country <br /> Yes U Private X New Permit 1221 ❑Yes <br /> 1XI No ❑Federal _ Permit Renewal ❑X No <br /> ❑State/Tribal/ Modification <br /> Municipal r Add Well to Area Permit <br /> r Other <br /> Vill. Type of Permit(For multiple wells,use additional page(s)to provide the information requested for each additional well) <br /> X A. Individual Number of Wells Well Field and/or Project Names <br /> ❑B.Area 1 Cols owyo Mn, <br /> IX. Class and Type of Well(see reverse) <br /> A.Class B.Type(enter code(s)) C. If type code is"X,"explain. <br /> V I <br /> X. Well Status XI. Well Information <br /> A.Operating ❑ B.Conversion XC.Proposed API Number <br /> Date Injection Started Date Well Constructed Permit(or EPA ID)Number <br /> Full Well Name Colowyo Mine East Taylor Seep lNJ#1 <br /> XII. Location of Well or,for Multiple Wells,Approximate Center of Field or Project <br /> Locate well in two directions from nearest lines of quarter section and drilling unit Latitude 40°15'40.65"N <br /> Surface Location <br /> SE 1/4 of®1/4 of Section 4 Township 3N Range 93W Longitude 107'50'4.22"W <br /> 1 900 ft.from(N/S) Line of quarter section <br /> 1 400 ft.from(E/W) Line of quarter section. <br /> RP RP XIII.Attachments <br /> In addition to this form, complete Attachments A-U (as appropriate for the specific well <br /> class) on separate sheets. Submit complete information, as required in the instructions and <br /> list all attachments,maps or other figures,by the applicable letter. <br /> XIV. Certification <br /> I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this document and all attachments <br /> and that,based on my inquiry of those individuals immediately responsible for obtaining the information,I believe that the information is true, <br /> accurate,and complete. I am aware that there are significant penalties for submitting false information,including the possibliity of fine and <br /> imprisonment. (Ref.40 CFR§144.32) <br /> Name and Official Title (Please Type or Print) Sir�dRusigned by: Date Si ned <br /> Barbara A.Walz,SVP,Policy&Compliance/CCO 1 <br /> av'l�av'a �a.�j <br /> EPA Form 7520-6(Rev. 4-19) <br />