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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS 46(01/2020) <br /> DEPARTMENT OF NATURAL RESOURCES _ <br /> 1313 SHERMAN ST.,Ste 821,DENVER CO 80203 <br /> Phone: 303 866-3581 dwrDermitsonline0state.w.us <br /> MONITORING/OBSERVATION <br /> Water Well Permit Application <br /> Review instructions on reverse side prior to completing form. <br /> The form must be typed,completed online or in black or blue ink. <br /> 1.Well Owner Information <br /> Name of well owner 6.Use Of Well <br /> Sunset Industrial,LLC. Use of this well is limited to monitoring water levels <br /> Mailingaftess and/or water quality sampling <br /> 1050 Coronado Ct., Unit A-101 7.Well Data(proposed) <br /> City State 21p ode <br /> Total deem Muller <br /> Ft. Collins CO 80525 <br /> 114 feet alluvial <br /> Telephone# E-Mall(If tllingordirteItlsrequlred) 8.Consultant Information(if applicable) <br /> 970.219.3916 chdsleone@j2contracting.com Name ofC0ieaperson <br /> 2.Type Of Application(check applicable boxes) Jay B. Edwards <br /> ❑Use existing well ❑Replacement for existing monitoring well: Company name <br /> ®Construct new well Permit no.: Cesare Inc./CMT Technical Services <br /> ❑Other. Meiling address <br /> 3. Refer To(if applicable) 7108 S.Alton Way Bldg B. <br /> Manitatng hole aclumMAedgment well name or III Clty state Zp code <br /> MH- 63811 MW-1 Centennial CO 180112 <br /> 4.Location Of Proposed Well Im ortantl See Instructions Telephone# <br /> County 303.220.0300 <br /> Weld NE 114ofthe SW IM 9, Proposed Well Driller License#o tional : <br /> sermon Township I Nors Range I E or W Pnndpal LWdian 10.Name of Well Owner or Authorized Agent <br /> 3 5 r 65 F- r 6 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(13xa). I have read the statements herein,know the contents <br /> Dtstance of wen from section lines(section lines are typically not property lines) _ thereof and state that the are true tom knowledge. <br /> Ft from(— N( S Ft.from l E I W Sign or enter full name here Date(mm+ddiyyyy) <br /> For repacement Vans only—tltsrence and direobon from old wan to new wit Jay B. Edwards 109/13/2022 <br /> feet direction If signing print name Pnnt title if other than land owner. <br /> Well location address(Include City,State.Lp) check swan address is same as Item 1. Engineering Field Services Coordinator <br /> n/a <br /> Office Use Only <br /> Optional: GPS wag bcation information in UTM format <br /> You must check GPS unit for required settings as follows: USGS map creme DWR map no. Surface eiev. <br /> Format must be uTM <br /> (—zone 12 or Zone 13 Easting 529731 Receipt area only <br /> units must be Meters <br /> Daum least be Haines Northing 4475202 <br /> unit mat be set ro irue norm <br /> Remember to set Datum to NAD83 <br /> Was GPS unit ohedted for above? ❑YES <br /> 5.Property Owner Information <br /> Name of property owner <br /> Same as well owner <br /> Malting address <br /> city, state rp code <br /> Tdwhom# <br /> DIV_ WD_ BA_MD _ <br />