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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 dwroermitsonfinefttate.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 /> Nam of wart owner 6.Use Of Well <br /> Sunset Industrial, LLC. Use of this well is limited to monitoring water levels <br /> Mang aedrm and/or water quality sampling <br /> 1050 Coronado Ct., Unit A-101 7.Well Data(proposed) <br /> City <br /> State Zip code Trial depth Aquifer <br /> Ft. Collins CO 80525 94 feet alluvial <br /> Telephonetr E•Mail(r Ming online Itisrequired) 8.Consultant Information(if applicable) <br /> 970.219.3916 Fhdsleone@j2contracting.com Name of contactperaon <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: Mailing address <br /> 3.Refer To(if applicable) 7108 S.Alton Way Bldg B. <br /> M7Zip Code <br /> onitoring hole edmoMedgment Well name or# CRY stale <br /> MH- 63811 MW-3 Centennial CO 80112 <br /> 4. Location Of Proposed Well Im ortantl See Instructions TmephoneCounty tF <br /> 303.220.0300 <br /> Weld SE 114ofthe SW tra 9.Pro osed Well Driller License#o tional : <br /> Secbor. Township I N oa S Range E or W Pnnapai Menaan 10.Name of Well Owner or Authorized Agent <br /> rx` I- r r 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 well from section lines(section fines are typically not property lines) thereof and state that they are true to my knowledge. <br /> Ft.from i N(— S Ft,from r E r W Sign or enter full name here Date(mnYddlyyyy) <br /> For replacement wells only—distance and direction from old wen to new well Jay B. Edwards 09/13/2022 <br /> feet direction if signing print name.Print iige if other than land owner. <br /> Welt location address(Include city.State,Zip) OCheavymoaddressissamessiterni. Engineering Field Services Coordinator <br /> n/a Office Use Only <br /> Optional: GPS well ktcatkiri information in UTM format <br /> You must check GPS unit for required settings as folbws: USGS map name DWR map no. surface elev. <br /> Format must be UTM <br /> r-zone 12 or f zone 13 Easting 529469 Receipt area only <br /> Units must be Meters <br /> Datum must be NAM Northing 4474868 <br /> Unit must be set to true north <br /> Remember to set Datum to NAD83 <br /> Was GPS unit ctwdled for above? ❑YES <br /> 5.Property Owner Information <br /> Name of property o ater <br /> Same as well owner <br /> Mailing address <br /> City state Zip Code <br /> Telephone <br /> DIV WO BA MD <br />