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FORM No. STATE OF COLORADO Oak. umQws- only <br /> arso, 27 OFFICE OF THE STATE EGNEER <br /> a=C�nid awe, 1313 Shr at, Dw ,Colorado aDzoa <br /> PM 86"W t <br /> SEE INSTRUCTIONS ON REVERSE SIDE <br /> GRAVEL PIT WELL PERMIT APPLICATION <br /> 1. E OF PERMIT <br /> 0 NEW Prr(S) <br /> ❑ Prr(S) EXIST, CONSTRUCTED AFTER DEC. 31, 1980 <br /> ❑ REACTIVATION OF PRE JAN. 1 1981 Prr S <br /> 2. OWNER <br /> NAME(S) Cooley Gravel Co . <br /> Mailing Address P .O . Box 5485 <br /> City, St Zip Denver , CO 80217 <br /> Phone (303 1 989-0300 <br /> 3. ADDRESS OF LOCAL CONTACT (If different than *2) <br /> NAME(S) Tom Hatton <br /> Mailing Address 4851 Independence St . Suite 248 <br /> Gty, St Zip Wheat Ridge , CO 80033 <br /> Plione ( 303 ) 422-5656 <br /> 4. GENERAL LOCATION OF Prr(S): COUNTY Adams <br /> E/2 19 <br /> 1/4 W22 1/4, Sec. Twp.__ _ ❑ N. ® S., Range 67 El E. E W. 6th P.M. <br /> 5. Total number of water surface acres (to be) exposed 30 Taal Number of Pits 1 <br /> 6. Estimated total depth of pit 20 Estimated depth to groundwater 5 <br /> 7. (a) Estimated date to begin excavation 6/9 5 to complete excavation 1998 <br /> 8. ATTACHMENTS: (Check which have been attached.) <br /> (a) Scaled map of pit area tied to a Section or 114 Comer (Required). <br /> (b) ❑ Copy of the reclamation permit if applicable. <br /> (c) ❑ Copy of Pre 1/1Stag Water Conservancy DisL or Water User Assoc. Augmentation Agreement if applicable <br /> (d) 0 Copy of proposed Augmentation or Temporary Supply Plan if applicable. <br /> (fI ❑ Copy of Court approved Augmentation Plan ff applicable. <br /> (n ❑ Other <br /> 9. Detailed description of the use and method of diversion of any water withdrawn from the pond. <br /> Evaporation of exposed ground water , and water removed with product <br /> 0. I (we) have read the statements made herein and know the contents thereof, and that they are true to my (our) <br /> knowledge. (Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perju <br /> in the second degree and is punishable as a class 1 misdemeanor.j <br /> Name/Title (pre•type a pnrm IS <br /> ignature ate <br /> For OIRos Ue 0* <br /> Court Case No. Div. Co. WE) Basin MD Use <br /> Page 15, EXHIBIT G-1 <br />