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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 dwrp2itsonline(&state.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 slate zip code Total depth Aquifer <br /> Ft. Collins CO 80525 79 feet alluvial <br /> Telephone# E-Mail(ar*„g online itisrequired) 8.Consultant Information(if applicable) <br /> 970.219.3916 ch6sleone@j2contracting.com Nam 01 contact paradn <br /> 2.Type Of Application(check applicable boxes) Jay B.Edwards <br /> ❑Use existing well ❑Replacement for existing monitoring well: many 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 /> Monitoring riots awxWedgment Well name or# City state zip Code <br /> MH- 63811 MW-5 Centennial CO 180112 <br /> 4.Location Of Proposed Well Im ortantl See Instructions T"eohone# <br /> county 303.220.0300 <br /> Weld NW 1/4ofthe SW 114 9.Proposed Well Driller License#o tional : <br /> section Township I N ors Range E or W I Principal Mendian 10.Name of Well Owner or Authorized Agent <br /> Ix r 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 I,(13Ka). I have read the statements herein,know the contents <br /> Distance of well from section lines(section lines are typically not property tines) thereof and state that they are true to my knowledge. <br /> Ft froml' N r S Ft.from F E F W Sign or enter full name here Date(mmhldlyyW) <br /> For redacement wells only—distance and direction from old well to new well Jay B. Edwards 09/13/2022 <br /> feet direction d stgnmg print name Print btie If other than land owner. <br /> Well location address(Include city.state,7jp) 0 check ifwell address is same as Item 1. 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: uses map name DWR map no. surface Slay. <br /> Format must be UTM <br /> I'zone 12 or r Zone,13 Easung 529148 Receipt area only <br /> Units must be Meters <br /> Datum must be NAD83 Northing 4475270 <br /> Unit must be set to true north <br /> Remember to set Datum to NAD83 <br /> Was GPS unit checked for above? ❑YES <br /> 5.Property Owner Information <br /> Name Of property owner <br /> Same as well owner <br /> Malting address <br /> city state Zip Code <br /> Telephone# <br /> DIV_ wD_ BA_MD <br />