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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 dwrpermitsonline@state.co.ua <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 /> Highbury Resources Inc. c/o Richard Peterson Use of this well is limited to monitoring water levels <br /> Mailing address and/or water quality sampling <br /> P.O. Box 700 7.Well Data (proposed) <br /> City State Zip code Total depth FAquilerNucla CO 81424 <br /> 900 feetash <br /> Telephone# E-Mail(Iffilingonlineitisrequired) 8. Consultant Information (if applicable) <br /> (970)433-1940 Name of contact person <br /> 2. Type Of Application (check applicable boxes) Doug Beahm <br /> ❑ Use existing well ❑ Replacement for existing monitoring well: Company name <br /> E Construct new well Permit no.: BRS Engineering <br /> ❑Other: Mailing address <br /> 3. Refer To (if applicable) 1130 Major Ave. <br /> Monitoring hole acknowledgment Well name or# City State F82501 <br /> ode <br /> MH- Riverton WY <br /> 4. Location Of Proposed Well (Important! See Instructions) Telephone# <br /> County (307)857-3079 <br /> San Miguel NE 1/4ofthe NW 1/4 9. Proposed Well Driller License#(o tional): <br /> Section Township I N ors Range I E orw I Principal Meridian 10. Name of Well Owner or Authorized Agent <br /> The making of false statements herein constitutes perjury in the second <br /> 34 44 18 r 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 lines are typically not property lines) thereof and state that they are true to my knowled e. <br /> 1120 Ft.from N F- S 2500 Ft.from F- E I^W Sign or enter full name here =atem dd/yyyy) <br /> For replacement wells only—distance and direction from old well to new well <br /> feet direction If signing print name. Print title if other than land owner. <br /> Well location address(Include City,State,Zip) ❑Check if well address is same as Item 1. <br /> 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 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 /> Bureau of Land Management-Tres Rios Field Office <br /> Mailing address <br /> 161 Burnett Drive- Unit 4 <br /> City State Zip Code <br /> Durango CO 81301 <br /> Telephone# <br /> DIV WD BA MD <br /> Bridget Wade- (970) 385-1342 <br />