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rcrr7(7,3.~ <br />Gam/ ~rr: /~ /~t? <br />COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES Office(~I~~~~~ Form G 5-45 (6x1003) <br />(( <br />~J <br />1313 SHERMAN ST., RM 618, DENVER, CO 80203 <br />i <br />fo: (303) B66-3587 <br />( <br />h <br />i <br />303 <br />866 <br />3581 ,, <br />n <br />p <br />one- <br />ma <br />n: ( <br />) <br />- //,,,, / <br />~ ~~ Qb <br />~~ <br />- <br />~ <br />tax: 303) 866-3589 http://www.watecstate.co.us b <br />f <br />/ <br />1 - <br />u o ~ •~ <br />i <br /> ;~ <br />GENERAL PURPOSE <br />/ Ce~v7k~l /~4GQtgA7vs <br />Water Well Permit Application t ~~~~ 7 ~ a/. 0l6 J <br /> <br />Review insVUCtions on reverse side prior to completing form. ~E <br />The forth must be completed in black ink. <br />1. A licant Information 6. Use Of Well {check applicable boxes) <br />Name of applicant Attach a detailed description of uses applied tor. <br />Central Aggregates, Inc. ^ Industrial l~l other (describe): <br /> <br />Mailing address - ^ Municipal <br /> <br />250 R i1;ghTv 624- <br />. ^ Irrigation <br />Recreation & Piscatorial <br />c-H stela rP COee <br />I ^Commercial <br />u; fl P fr3 I 81650 7 <br />Well Data ( <br />ro <br />osed <br /> <br />Telephone e . <br />p <br />p <br />) <br /> Maumum pvmPirg rate Annual amount to ba wiebrawn ------- <br />( - <br />gpm <br />2. Type Of Application (check applicable boxes) 85 _ f,5,~ acre-feet <br /> <br />^ Construct new well ~) Use existing well 7o1a1 tlepm Aquifer <br />^ Replace existing well (~ Change or increase use feet <br />^ Change source (aquifer) ^ Reapplication (expired permit) 8. Land-On Which Ground Water WiII Be Used <br />^ Other. Legal Description (maybe provitlee as an anarhmenl): <br />3. Refer To (if applicable)_ <br />Well pemdl R ( Water Court case tl <br />042041-F 0"~fG1290/R1(Z4111 /90CG7150 <br />- N/A <br />Designated Basin Determinalion~ Well name w~ <br />' <br />I / <br />4. Location Of Proposed Well <br />If <br />tl f <br />i <br />i <br />b <br />tt <br />h <br />l <br />d <br />h <br />h <br />i <br />i <br />d <br />CalrnH use <br />or aop <br />n <br />ga <br />on, a <br />ac <br />( <br />a sca <br />e <br />map t <br />at s <br />ows <br />rt <br />gate <br />area.) <br />- <br />I ~,f va w Ina ~ va <br />(pr'irfi al A <br />~ A. re Arrea <br />1 j B. o.ner <br />Becbon Toxnship NorS <br />Rango EorW I Principal Meridian __ ____ <br />I <br />17 <br />6 ^ ~ I 93 (~7 ^ I (~ __-. <br />o. ual any w,ar wells or warer dghrs used en wa land: <br />Distance o/wan from sedian fines (section lines are HpiealH nm properly fines) <br />,~qpn Ft rrom ^ N ~C] s 2500 FL from ~ E ^ w g, pro osed Well Driller License # o tional <br />For replacemrun walls pNy-dislancs and dvedian from oltl well to new well <br />t di <br />f <br />ti 10. Signature Of Applicant(s) Or Authorized Agent <br />rec <br />ee <br />on The making of false statements herein constitutes perjury in the second <br />Well location address (if applicable) degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br /> 244-104 (13)( I have read the statements herein, know the contents <br />~3.~ <br />optional: PS well tiorrinfortnation In TM coat thereof ands t that the are true to my knowledge. <br />Required settings for GPS units are as follows: Sign oars (Masi rtglnar sig ) Date <br />I/ <br />l <br />Formal must ba IITM I L <br />12 <br />Zone must be 10 I Northing name 8 b e <br />Unit must ba Meters I <br />Datum must be NA09 (CONUu) , <br />G#;7. 'ee P es'de <br />Unit rmnt ba set to bus north ~ Fasting Office Use Only <br />Were poims averegad9 ^YES ^ NO f USGS map name I D WR map no. Surtace elev. <br />5. Parcel On Which Well Will Be Located <br />A. Legal Description (may be Prwitlee as an anactvnenlx Receipt area only <br />RECEIVED <br />See Attachefl <br />JUL 312006 <br />as Nimara(s and CaedoOY <br />O,m,.eldn <br /> wE <br />a. p of ease in Parcel i C. Owner 4VR <br />approx. 34 ~ Central Aggregates, Inc. cwcB <br />D. Will Nla be the onlywell on this parcal~~]VES ^NO (il no-IislaNar walls) TOPD <br />__ _ __ __ _ <br />E. Stale Portal l0#(opnanap: <br />---~_-~-~-----~-~~--~ - MYIAR - <br /> <br />MD <br />5e5 ON ~ WD `~ eA <br /> _,_ <br />_ <br />2177-171-00-044 _ - _-.__._ <br />