2023-11-21_GENERAL DOCUMENTS - M1974069

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As COLORADO DIVISION OF WATER RESOURCES Office Use Only :+ ! Farm GWS a6(11/2011) DEPARTMENT OF NATURAL RESOURCES 1313 SHERMAN ST.,Ste 821,DENVER CO 80203 Phone 303 866-3581 Fax 303 866-2223 dwr ermitsonline state co us its MONITORING/OBSERVATION Water Well Permit Application Review Instructions on reverse side prior to completing form. IF tIF`,r:`• `., The form must be typed,completed online or In black or blue ink. 1.Well Owner Information Name of well owner 6. Use Of Well Loveland Ready Mix, Inc. Use of this well is limited to monitoring water levels Mailing address and/or water quality sampling P. O. Box 299 7.Well Data (proposed) City State Zip code Total depth TAquiferLoveland CO 80539-029920 feethompson Telephone# E•Mail(if filing oNineitisrequired) 8.Consultant Information (if applicable) 970-667-2680 1 Name of contact person 2.Type Of Application (check applicable boxes) Larry Miller E Use existing well ❑Replacement for existing monitoring Well: Company name ❑Construct new well Permit no.: Landmark Engineering Ltd ❑Other: Mailing address 3. Refer To(if applicable) 3521 West Eisenhower Blvd. Monitoring hole acknowledgment Well name or# City State Zip Code MH- 053386 Well#1 Loveland CO 180537 4. Location Of Proposed Well (important! See Instructions Telephone 970-667-6286 ext 209 County Larimer SW 1r4 of the SW 114 g, Proposed Well Driller License# cl tional : Section Township I N or S Range E or W Principal Mendian 10. Name of Well Owner or Authorized Agent 15 5 Ix I 69 r f 6th The making of false statements herein constitutes perjury in the second degree,which is punishable as a Gass 1 misdemeanor pursuant to C.R.S. 24-4-104(13)(a). I have read the statements herein,know the contents Distance of well from section lines(section lines are typically not property lines) thereof and state that they are true to my knowledge. 628 Ft frorrii— N IX S 39 Ft from r- E Ix W Sign or enter full name here Date(mnvddlyyyy) For replacement wells only-distance and direction from old well to new well Larry Miller 03/10/2015 feet direction It signing print name Print title if other than landowner Well location address(Include Gry.State.Zip) 0 Check ifweli address Is same as item 1. Larry Miller, Consultant Loveland, Colorado, 80537 Office Use Only Optional: GPS well locabon Information in UTM format You must check GPS unit for required settings as follows USGS map name DWR map no Surface elev Format must be UTM I—Zone 12 or r-Zone 13 Easting Receipt area only Uruts must be Meters Datum must be NAD83 Northing Unit must be set to true north Remember to set Datum to NAD83 Was GPS unit checked for above? ❑YES S. Property Owner Information Name of property owner Big Thompson Farms 1r�n,�ctioflt/. :;6f;$?3F+G Mailing address Dana (1(]j1t11ri 7'15.:i3 PM 7i itl'.fe't'ta'tl T[tt:d. g•j�17�Q P. O. Box 299 gin 0 CIO City state Zip Code Loveland CO 80539-0299 Telephone# L DIV WD BA MD _ 970-667-2680