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I t d`7 <br /> COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(07/2013) <br /> DEPARTMENT OF NATURAL RESOURCES RECEI`� <br /> 1313 SHERMAN ST, RM 821,DENVER,CO 80203 <br /> Main: 303 866-3581 Fax 303 866-2223 dwrDermitsonlineastate <br /> GENERAL PURPOSE �g 0 5 2015 <br /> Water Well Permit Application <br /> uR s <br /> Review instructions on reverse side prior to completing form. TEJ INE R <br /> The form must be computer generated,typed or In black or blue ink. C0� <br /> 1. Applicant Information <br /> Name of applicant 6. Use Of Well (check applicable boxes) <br /> Na <br /> Attach a detailed description of uses applied for <br /> Connell Resources, Inc. <br /> ❑ Industrial ❑ Dewatering System <br /> Mailing address ❑ Municipal ❑ Geothermal(production or reinjection <br /> 7785 Highland Meadows Pkwy, Ste 100 ❑ irrigation <br /> Coy State Zip code ❑ Other(describe) <br /> Fort Collins CO 80528 ® Commercial <br /> Telephone it(area code&number) E-mail(online tiling required) 7.Well Data (proposed) <br /> 970-223-3151 1 Mawmum pumping rate Annual amount to be withdrawn <br /> 2.Type Of Application (check applicable boxes) 150 gpm 50 acre-feet <br /> ❑Construct new well ❑ Use existing well Total depth- _ - Aquifer <br /> © Replace existing well ❑ Change or increase use 900 feet all unnamed aquifer <br /> ❑Change source(aquifer) ❑ Reapplication(expired permit) $, Land On Which Ground Water Will Be Used <br /> ❑COGCC Well Other <br /> Legal Description Of Land(may be provided as an attachmenq <br /> 3. Refer To (if applicable) <br /> Well permit M Water Coun case a Section 17,Township 11 N, Range 67W, sixth PM <br /> 25144-F <br /> Designated Basin Deternnabon a Well name of-11 Section 21,Township 11 N, Range 67W, sixth PM <br /> Laramie-Fox Hills <br /> 4. Location Of Proposed Well DRMS-M-1980-002-Tucker& M-2014-001-Connell-Carr <br /> County (If used for crop irngation,attach a scaled map that shows irrigated area) <br /> Weld :SW 114 of tine NE 114 A if Acres B Owner <br /> Section ( Township Nor S Range E or W Primpai Menaan <br /> �I I^1 <br /> 17 ill 67 171 El 6 C List any other wens or water rights used on this land <br /> Distance of welf from section lines(section lines are typically not property lines; <br /> 2540 Ft from rx N(_S 2440 Ft fro47xE❑W <br /> For replacement wells only-distance and direction from old wail to new well 9. Proposed Well Driller License#(optional) <br /> 200 feet East or South direction 10. Sign or Entered Name Of Applicant(s)Or Authorized Agent <br /> wev location address(,ndude City Stale Zip) ❑Check,f well address,s same as in item 1 The making of false statements herein constitutes perjury in the second <br /> 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 /> thereof and state that the are true to my knowledge <br /> Optional: GPS well location information in UTM format You must check GPS unit for Sign or t name(s n(s suDmitting application Date immiwiyyyy) <br /> required settings as follows <br /> Format must be UTM sign t name and He <br /> (-I Zone 12orlr I Zone 13 Easting / /� y1.,, D �/�y J <br /> units must be Meters �(� Y Cvny)_ / 'f-Si"t!4T <br /> Datum must be NAD63 Northing Office Use Only <br /> Unit must De set to true rlonh <br /> YES USGS map name DWR map no Surface elev <br /> Was GPS unit checked for above) <br /> ❑ Remember to set Datum to NADB� <br /> 5. Parcel On Which Well Will Be Located <br /> (PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) Receipt area only <br /> A. Legal Description(may be provided as an aaacnment) L )VLA <br /> SW 1/4 of NE 1/4 of Section 17,Twp 11 N, Range 67W, 6th PM <br /> B at of acres in parcel C Owner AOUAMAP <br /> a <br /> WE <br /> T_arty Grazing Assn <br /> WR 1 <br /> D �Wis this De the only well on;his parcel) E]YESr]NO(if no tist other wens) ' I if (.K t.j;s r l•' <br /> CWCB <br /> TOPO <br /> E State Parcel iDN(optional) MYLAR <br /> SB5 Div- WD_ 8A_ MD _ <br />