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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) 866-3587 main: (303) 866-3581 Office Use Only Form GWS,46 (702004) <br />MONITORING/OBSERVATION <br />Water Well Permit Application <br />Review Instructions on reverse side prior to completing form. <br />The form must be com leted In black or blue Ink or t ed. <br />1 W II Ow er In ormation 6. Use Of Well <br />NamB d wep owner <br />Cripp)e Creek & Victor Gold Mining Company <br />Use of this well Is limited to monitoring water levels <br />and/or water quality sampling <br />Meillrp address <br /> 7. Well Data (proposed) <br />PO Box 191 Awls <br />Clb state ztp soda 140 feet N/A <br />Victor Colorado 80860 8. Consultant Information (if applicable) <br />Telephone a <br />( 77 s) s6s-2sn Name d cooled person <br />N/A <br />2. Type Of Application (check applicable boxes) anpany^~ <br />Use existing weU ^ Replacement for exisdng monitoring well: <br />^ Construct new well <br />^ Other: Permit no.: Magog eddmas <br />3. Refer To (if applica ble) oly stare apcade <br />Monaoring hde edawwledgrrom We0 riarra m <br />MH-43265 ~ VIN-2B reMpno~wtl <br />4. Location Of Pro osed Well ( ) <br />c0°^ty 9. Pro osed Well Driller License # o tional <br />Teller NE vsame NE ,u 10 Signature Of Well Owner, Consultant Or Authorized <br />Sadlon Township N or S Range E or W Pendpd Medtlimi A ant <br />29 15 ^ ® 69 ^ ® 6th The making of false statements herein constitutes perjury in the second <br />degree, which is punishable es a class 1 misdemeanor pursuant to C.R.S. <br />Clatence d wetl Irom seclbn Wne6 (9edbn ones ere ryykaey nd propeM lines) 24-4.704 (73)(a). I have read the statements herein, know the contents <br />thereof end state that the are true tom knowled e. <br />^i ~•) R imm ®N ^ S -600 FL barn ^E ®W ere ne mg/n/elure Date <br />For mpkcemant welb only-distenea and daectlon hom del wellro new wetl <br />N/A % /~~ ` / r~ <br />LL ~v0~/OS <br />feet direction Print name a gre <br />Well beetlon ea'dresa PI epplkade) <br />N/A <br />Timm Comer, Chief Environmental Coordinator <br /> <br />Opdonel: GPS well location inlortnatlon In UTM format Office Use Only <br />You must check GPS unit for required seNngs as fellows: USCG map name DNR map no. Sudece elev. <br />Format must ire UTM <br />zone moat bets Eesgng Receipt area only <br />Unite must tre Melers <br />OaNm moat M NAUeg <br />Unit mud be set to true rmM <br /> <br />Nodhinq <br />Was GPS unX checke0 fa eboveT ^ YES Remember to Bet Datum 10 NADB3 <br />5. Property Owner Information <br />Name d pmpeM owner <br />Cri le Creek & Victor Gold Minin Com an <br />Meiling address <br />PO B <br />191 <br />ox <br />CIN Sate nP Cade <br />Victor Colorado 80860 <br />Telephone R <br />( 77 s) s6s-2sr7 <br /> <br />DIV_ WD_ GA ~~MD <br />