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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SI-IERMAN ST., RM. 818, DENVER CO 80203 <br />phone -info: 1303) 866-3587 main: 13031 866-3581 <br />MOIVITORING/OBSERVATION <br />Water Wel'I Permit Application <br />Review instructions riot to com Ietin form. <br />Must be cortl leted in black ink or ed <br />1. APPLICANT INFORMATION 6. USE OF WELL <br />Nema el epplivrt ^ GROUND WATER SAMPLING (QUality) <br />^ MONITOR WATER LEVELS <br />^ OTHER: <br />I.wlno aaarm 7. WELL DATA <br /> tool arvtn <br />feet Aqufer <br />city strte , zueea. g, CONSULTANT INFORMATION ioptionaq <br /> None <br />Ttlcghpte nunen frclutla rm Dees) <br /> btlrer <br />2. TYPE OF APPLICATION (check ap linable boxles)) <br />^ Use existing well ^ Replacement for - <br />^ Construct new well permit no. rtlepren. r..nes nnuw..e. maei <br />^ Other: 9. PROPOSED WELL DRILLER to ionaq <br />3. REFER TO (if applicablel: cempenr rorro lxarw r..nDs <br />Monitoring hob ecknowledpmerrt t Well name or <br />MH- 10. SIGNATURE of ap licantlsl or authorized agent <br />4. LOCATION OF WELL The making of false statements herein constitutes perjury <br />Ceunry Quarter/quarter <br />ts nuerter <br />%. in the second degree, which is punishable as a lass 1 mis- <br />demeanor pursuant to C.R.S. 24-4-104(1311a1. I have read <br />section Towrrhip N ar S <br />^ ^ Range E or W <br />^ ^ RIrciW Meaalen the statements herein, know the conterns thereof, and state <br />that they are true to my knowledge. <br />Dirtenee of well Imm section linos <br />ft. from ^ N ^ S ft. hom ^ E ^ W Mot na orryrrr elarotva <br />Wdl leutien eaerm, it aiRsern from eppllun[ etltlrew @ epplluWel <br /> Prim rome IeelGly <br />For replecen~[ wtlb only ~ abunca rtl art,caon Irom ola wtll to rerw wtll <br />feet direction T1tla °ite <br />5. OWNERSHIP INFORMATION <br />WELL OWNER NAME fie ainerent thenepdiunq See the reverse side of this farm for instructions, fee, and <br />adviso information <br />A°"`°' OPTIONAL INFORMATION <br /> uscs m.p nvrw DwR m~ ro. s,l.ee d«. <br />Clry Soto Zlp Coaa 1 O L <br /> Office Uee Only <br />Ttleylnro ro. lirckda nee coael 2~ 4 4 3 9 5 g <br />rjee flU ,~+- M ~ J. Ma•fi'^e 3.~wc2~ <br />DIV <br />PIIDPERTY OWNER NAME Ia etlraent tnen ebwal SQ e K ~ 5~~ I I ; v. h ~' D. M c E.I ti.~e y . <br />-d <br />Aearee er. <br />(3DE o. <br />WD <br />Cary +hne Zlp Coaa I <br />BA <br />Tdrolero ro. IlMUtle err weal <br />USE MD <br />Form GWS~6 (12/95) <br />