2023-01-10_PERMIT FILE - M2023001 ‎(12)‎

• Permit No: M2023001
• IBM Index Class Name: Permit File
• Doc Date: 1/10/2023
• Doc Name Note: Exhibit G - Water Information
• Doc Name: Application
• From: J-2 Contracting Company
• To: DRMS
• Email Name: PSH
• Email Name: JLE
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(01/2020)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,Ste 821,DENVER CO 80203
Phone: [phone] wr rrni nline s
MONITORING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be typed,completed online or in black or blue ink.
1.Well Owner Information
Name of wen owner 6.Use Of Well
Sunset Industrial,I.I.C. Use of this well is limited to monitoring water levels
Wing address and/or water quality sampling
1050 Coronado Ct., Unit A-101 7.Well Data(proposed)
city stab zip code Total der»tr A"Ifer
Ft.Collins CO 80525
44 feet alluvial
Telephonell E-Mail(If Ming oMineitislequired) 8.Consultant Information(If applicable)
970.219.3916 [e-mail] Name of contact person
2.Type Of Application(check applicable boxes) Jay B.Edwards
❑Use existing well ❑Replacement for existing monitoring well: company name
i Construct new well Permit no.: Cesare Inc./CMT Technical Services
❑Other. Mailing address
3.Refer To(if applicable) 7108 S.Alton Way Bldg B.
Monitoring hole aclmowtedgment well name or x city IT�7
Zip code
Mkt- 63811 MW-4 Centennial 80112
4.Location Of Proposed Well Ion ortantl See Instructions Telephoned
� 303.220.0300
Weld SW 114ofthe SW 114 9.Proposed Well Driller License#o tional :
Section Township I N or S Range I E or w Principal Meridian 10. Name of Well Owner or Authorized Agent
r r i- The making of false statements herein constitutes perjury in the second
3 5 65 6 degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104(t3Xa). i have read the statements herein,know the contents
Distance of wen horn section lines(secbcn Ines are typically not property lines) _ thereof and state that the are true tom knowledge.
Ft from—_ N( S Ft.from( E F W Sign or enter fun name here Date(mModlyyytr)
For replacement wens only—distance and direction from old weato new well Jay B. Edwards 09/13/2022
feet direction If Signing print name. Print Ise if other than land owner.
Well location address(Include Oty,State,Zip) 0 Check Owen address is same as Item 1_ Engineering Field Services Coordinator
n/a Office Use Only
optional: GPS well location Information in UTM format
You must check GPS unit for required settings as follows: USGS map name DWR map no. Surface May.
Foment rtust be UTM
(-zone 12 or r Zonis 13 Fasting 529148 Receipt area only
units must be Meters
Datum must be NAD83 Northing 4474937
Unit must be set to Dive norm
Remember to set Datum to NAD83
Was GPS unit chocked for above? ❑YES
5.Property Owner Information
Name of property owner
Same as well owner
Mailing address
city state Zip code
Telephone p
DIV WD BA MD