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t <br />~\ <br />COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM. 818, DENVER CO 80203 <br />phone -into: (3031 866-3587 main: (3031866-3581 <br />R! (;FitrFU <br />( i. jf :~ :, jy,j, <br />„•.-, <br />GENERAL PURPOSE Water Welt Permit Application <br />(Please note: other loans are available for speci/ic ucec including - recidentrel, IIHeslock, monitonnQ/obsarv.. gravel pets, regislrerion of old wells) <br />Review instructions prior to completing form Must be completed in black ink or typed <br />1, APPLICANT INFORMATION 6. USE OF WELL (please attach detailed description) <br />N.nc of ..plan, // O~ ~~En ~~~ ~~~~ <br />^/ L <br />/ INDUSTRIAL r°t' OTHER: ./J(•ql ~//C '/ <br />- <br />LPL COMMERCIAL L/ r ~.> J <br />~`(,f~ <br />tU~ /~~lR~ 1/d ~ Lo MUNICIPAL <br />M.uro ^°°"~ t~ <br />yq IRRIGATION <br /> ^ FEED LOT -number of heed <br />P. U (jG ~- `~(c ~ 7. WELL DATA <br />Cilr Slnc Sip Ceaa Holman lu.npno nu M.r .rwwt <br /> /G'~ gpm ~ acre-feet <br />Uo(pEN <br />C'c: G~/CZ ipol Wpa ,wr« <br />, <br />•plaro,.e l+.M1lw rcldl.e. re.axt ~ <br />~ f <br />t / <br />/1'r1J~/ ~~C <br />_ W <br />ee !/ <br />303 - 2 7 7 - 3 ~fS <br />S ER WILL BE USED <br />_ 8. LAND ON WHICH GROUND WAT <br />2. TYPE OF APPLICATION (check applicable box(ed) A. LEGAL DESCRIPTION Imey be providee °. sn enechmen0: <br /> <br />^ Construct new well ^ Use existing well Por-icons of SQrt'tons ZS 4 31, <br />Replace existing well ^ Change or Increase Use 7w'P' 3 ~ ~~6~ <br />~~ <br />^ Change (source) Aquifer ^ Reapplination le~imd permrtl 1 <br />~~ f?n'1• ~'u1 w~iNq 785- °-CrCS <br />^ OCfler: Ill "pad for clop inpetion, ensch scaled de0 that shows Irrgeted eras.) <br />3. REFER TO lif applipblel: e. i.eR. c <br />JOWn.r <br />/ <br /> <br />Wa1el COVn Ceee~ <br />PGn^a/ ~1 (,/~SV ~F <br />p( y <br />E~\YL~ OP. ~' \ <br />` / <br />, <br />~I,C /,/ <br />l.~~RS W\-r~V r <br /> D. lirl °nY <br />rp0p °Ur dpht. u.ed on thl. lad: <br />otMc <br />Emelyency Verbal ! f'r'I . E/~ Monitorirlp M4 aekrowkdament ! a <br /># I I V33' <br />Fi'¢E .jOroTECTrOl1~ <br />-VE- a1-/~ 9 MH- <br />weu n.ma pr r 9. PROPOSED WELL DRILLER (optional) <br /> "'"` ~~G(lErrGr2Y l7ref./U.rU Dd't up... nunea <br />4. LOCATION OF WELL .17261Lr1t)G' ~Ri(~rl ~' ~ f207 <br />c°"^~ °i°n`r/0"~" n"°"`r~ 10. SIGNATURE of applicant(s) or authorized agent <br />~/ ~Q ~ t- %. S~ '/. The making of false statements herein constitutes perjury <br />section Tpwre:lip N or s Rena <br />e <br />E or w Priced M«iden in the second degree, which is punishable as a doss 1 mis- <br />f <br />ZJ ~ [~ ^ ' <br />[ <br />7 ^ ~ (~ f~l demeanor pursuant to C.R.S. 24-4-104(131(a). 1 have read <br />Distance of well Imm cectipn lines <br />Q y., ~ ,y/ <br />1r, <br />G <br />^ <br />^ <br />~ <br />O the statemems herein, know the comerrts thereof, and state <br /> <br />~ <br />fi /mm ICI E <br />W <br />S <br />N <br />n 7mm <br />t/ Ulct t <br />12y afC trJe i0 my knOWIEdsE. <br />W~ boom ed°,r. it da.rem hon eppYOrra edNe °t eposalM.l Mal ,sq'n.l4ptiNr I / <br /> <br /> <br />Fpr r.p.o..rm vc°s erry - e.a,n. a.e arsceen tmm aw ..o m Ir. w ' <br />L <br />i <br />C ~ -l ~ 4 <br /> t <br />! ! <br />o ~ - <br />.wl <br />r / <br />J'U feet ,Soc..tll direction OPTIONAL INFORMATION <br />5. TRACT ON WHICH WELL WILL BE LOCATED uscsm.p„p„c o\Hnm.eno. s„t.aw.,. <br />A LEGAL DESCRIPTION Imey be provided ez en enechmentl: <br /> <br />NE ~y St %[~ .SfL .:l S ~ /4-,c/ J'N, OffICC Ube O^y <br />DIV~ <br /> co ~~-- <br />6. STATE PARCEL 61 <br />CH,CK; TRk41~~5b C2~5,? <br /> <br />ID/lovtlprull: ~ <br />rltil ..r ~{~7rrl GEG~~:_.-- WD <br />C. ° w. H ereer U. <br />o .. c ~. .. <br />78 L'cr.-~5 Cti~t~G-~, BA <br />E. Will this be the only well on this Vent?.xI' //~,i,j <br />^ YE$ NO (if other wells are on this tract, cee instructions) U$E($I MD <br />Fonn GWS-t5 (12/95) <br />