Laserfiche WebLink
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 _dwrj;*rmitsonIineAstate.co.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 /> Mailing address and/or water quality sampling <br /> 1050 Coronado Ct., Unit A-101 7.Well Data(proposed) <br /> City state Zip code Total depth Aquifer <br /> Ft.Collins CO 80525 <br /> 114 feet alluvial <br /> Telephone# E-M■ll(If filing online 4isrequired) 8.Consultant Information(if applicable) <br /> 970.219.3916 chdsleone@j2contracting.com Name of contact person <br /> 2.Type Of Application(check applicable boxes) Jay B.Edwards <br /> ❑Use existing well ❑Replacement for existing monitoring well: dam hams <br /> ■Construct new well Permit no.: Cesare Inc./CMT Technical Services <br /> ❑Other Mailing address <br /> 3.Refer To(if applicable) 7108 S.Alton Way Bldg B. <br /> Monitoring hole acknowledgment well name or# city state Zip Code <br /> MH- 63811 MW-2 Centennial CID 180112 <br /> fl <br /> 4.Location Of Proposed Well Im ortantl See Instruction;T <br /> Telephone# <br /> County 303.220.0300 <br /> Weld SE 14ofthe SW 114 9.Proposed Well Driller License#o tional : <br /> seow Tawaamp I N or s Range E or W Pnnapal Meridian 10.Name of Well Owner or Authorized Agent <br /> r I— r fx The making of false statements herein constitutes perjury in the second <br /> 3 5 65 6 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 welt from section fines(section fines are typically not property lines) thereof and state that they are true to my knowledge. <br /> Ft from/ N r- S FL from I E F W Sign or enter full name here Date(mnyddlyyyy) <br /> For replacement welts only—distance and direction from old well to new well Jay B. Edwards 09/13/2022 <br /> Net direction If signing print name Print tole Bother than land owner. <br /> Well locaton address(Include City.state,Zip) check Itwel address is same as hem,. Engineering Field Services Coordinator <br /> n/a 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 [MR map no. Surface dev. <br /> Fornnal must be UTM <br /> r Zone 12 or r zone,) Essting 529731 Receipt area only <br /> Units roust to Meters <br /> Datum must be NAM Northing 4474930 <br /> unit must be set to true north <br /> Remember to set Datum to NAD83 <br /> Was GPS unit cheded for obese? ❑YES <br /> 5.Property Owner Information <br /> Name of properly owner <br /> Same as well owner <br /> Mailing address <br /> City state Zip Code <br /> Telephone# <br /> DIV WD BA MD <br />