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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER, CO 80203 <br />phone -Info: (303) 666.3587 main: (303) 666.3581 Office Use Only Form GWS-46 (10/2004) <br />MONITORING/OBSERVATION <br />Water Well Permit Application <br />Review Instructions on reverse side prior to completing form. <br />The Corm must be completed In black or blue ink or typed. <br />1. Well Owner Information 6. Use Of Well <br />Narre d x511 owner <br />Cripple Creek & Victor Gold Mining Company <br />Use of this well is limited to monitoring water levels <br />and/or water quality sampling <br />Mailing etltlresa <br /> Weld Data (proposed) <br />7 <br />PO Box 191 a ,~„Ir°r <br />~ s'°t° nv`°tl0 270 feet NIA <br />Victor Colorado 80860 8. Consultant Information (if applicable) <br />Teleplana R <br />( 719) 669-2977 Name d domed Verson <br />N/A <br />2. Type Of Application (check applicable boxes) Cgmpeny nacre <br />Use existing well ^ Replacement for existing monitoring well: <br />^ Constmd new well <br />^ Other: permit no.: Maumg eatlress <br />3. Refer To (if applicable) Gtr smte avcme <br />Monltorhq hde eckroaledyrent Wei rertq or R <br />MH- 43264 VIN-2A Telephone <br />4. Location Of Pro osed Well ( ) <br />c°°^ry 9. Pro osed Well Driller License # o tional <br />Teller NE t,Ratne NE ,ra 10. Signature Of Well Owner, Consultant Or Authorized <br />Seabn TawnshW NorS Range EarW PrlndpelMerlAen A ant <br />29 15 ^ ® 69 ^ ® 6th The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a class t misdemeanor pursuant to C.R.S. <br />Distance aver imrn aealon dreslaeonon ores ere tyvmaoy not prepeM Imes) 24-4.104 (13)(a). Ihave read the statements herein, know the contents <br />thereof and state that the are tme to m knowled e. <br />-1300 Ft. from ®N ^S -600 Fl. ham ^E ®W ere tb_ s g/reyture ate <br />For replacement wells ony-Wstereeand tlhecuon hom oltl weAbnew wall <br />NIA ~ / C' / /G}7~_ <br />I .r~e~~,~.,'._l/ ~2/07~~5 <br />feet direction Ptlntnerreaune <br />Wetl locatlon atldress (g appllrsbm) <br />N/A <br />Timm Comer, Chief Environmental Coordinator <br /> <br />Optional: GPS wall location IMortnatbn in UTM format Office Use Only <br />You must check GPS unit for required servings es lollows: USGe map name DWR map rw. 5utlace aev. <br />Format null ire lRM <br />Zare moat bets Fasting Receipt area only <br />DNIS must be Metere <br />Datum must be NADa1 <br />UNI rtusl be sal to irve noM <br /> <br />Nonhing <br />Was OPa unll checketl for appve9 ^ YES aemem5ar t0 Sat Datum to NAD83 <br />5. Property Owner Information <br />Nana a nrowm owns, <br />Cri le Creek & Victor Gold Minin Com an <br />Mailing address <br />PO B <br />191 <br />ox <br />Gry Stela Lp Code <br />ViotDr ('OlOfadO 8860 <br />Telephone N <br />(7t s) ses-zs77 <br /> <br />DIV WD_ 6A_ MD <br />