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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46(11/2011) <br /> DEPARTMENT OF NATURAL RESOURCES <br /> 1313 SHERMAN ST.,Ste 821,DENVER CO 80203 <br /> Phone 303 866-3581 Fax: 303 866-2223 quit ermltsonline state co.us <br /> MONITORING/OBSERVATION <br /> Water Well Permit Application <br /> Review instructions on reverse side prior to completing form. A ER <br /> The form must be typed,completed online or in black or blue ink. ZTATE ENGINEER <br /> 1.Well Owner Information Gli <br /> Name of well owner 6. Use Of Well <br /> Loveland Ready Mix, Inc. Use of this well is limited to monitoring water levels <br /> Mailing address and/or water quality sampling <br /> P. 0. Box 299 7.Well Data (proposed) <br /> City 4E-Mail <br /> Zip code Total depth FAquiferLoveland 80539-029920 feet hompson <br /> Telephone# (Irfilmg online it is required) 8.Consultant Information (if applicable) <br /> 970-667-2680 Name of contact person <br /> 2. Type Of Application (check applicable boxes) Larry Miller <br /> *Use existing well ❑Replacement for existing monitoring well: Company name <br /> ❑Construct new well Permit no.: Landmark Engineering Ltd <br /> ❑Other: Mailing address <br /> 3. Refer To(if applicable) 3521 West Eisenhower Blvd. <br /> Monitoring hole acknowledgment Well name or# CityState Zip Code <br /> MH- 053387 Well#3 Loveland CO 180537 <br /> 4. Location Of Proposed Well (Important! See Instructions Telephone# <br /> Canty 970-667-6286 ext 209 <br /> Larimer SE 114ofthe SE 14 9. Proposed Well Driller License# o tional : <br /> Section Township N or s Range E or W Principal Mandan 10. Name of Well Owner or Authorized Agent <br /> 16 5 f x f 69 f rx 6th 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(13)(a). I have read the statements herein,know the contents <br /> Distance of well from section Imes(section lines are typically not property lines) thereof and state that they are true to my knowledge. <br /> 13 Ft from!— N(-X S 1038 Ft from IX E F—W Sign or enter full name here Date(mWddlyyyy) <br /> For replacement wells orgy—distance and direction from old well to new well Larry Miller 03/10/2015 <br /> feet direction If signing print name Print title if other than landowner <br /> Well location address(Include City.State,Zip) Check if well address is same as Item 1 Larry Miller, Consultant <br /> Loveland, Colorado,80537 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 DWR map no Surface elev <br /> Format must be UTM <br /> I—Zone 12 or r Zone 13 Easting Receipt area only <br /> Units must be Meters <br /> Datum must be NAD83 Northing <br /> Unit must be set to We 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 /> Big Thompson Farms <br /> Mailing address 1).gtf,, -'sili it it T r; ';t r;"; <br /> P. 0. Box 299 <br /> (.REr)ll-r;p,RD �3ti17-fY) <br /> City State Zip Code <br /> Loveland CO 80539-0299 <br /> Telephone# L <br /> DIV WD BA_ MD <br /> 970-667-2680 <br />