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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-a6 (02/2005) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />phone -info: (303) 866-3587 main: (303) 866-3581 <br />Fax: 303) 866-3589 http://www.waterstate.co.us <br />MONITORING/OBSERVATION <br />Water Well Permit Application <br />Review instructions on reverse side prior to completing form. <br />The form must be completed in black or blue ink or typed. <br />1. Well Owner Information 6. Use Of We11 <br />Nacre o(well owner <br />Lafarge West, Inc. Use of this well is limited to monitoring water levels <br />c/o Water Resource Specialist andlor water quality sampling <br />Mailing addreaa 7. Well Data (proposed) <br />10170 Church Ranch Way, Suite 200 Total depth ~ AQUifer <br /> <br />city ~ state Zipcode feet j <br />35 <br />AIIUVial <br />I i <br />Westminster CO ~ 80021 <br />I 8. Consultant Information (if applicable) <br />Telephgne # Name of conlan pennon <br />(303>657-4000 Water Resource Specialist <br />2. Type Of Application (check applicable boxes) Company name <br />~ Use existing well ^ Replacement for existing monitoring well: Lafarge West, InC. <br />^ Cons W ct new wet I <br />Permit no.: Marring address <br />^ other: 10170 Church Ranch Way, Suite 200 <br />3. Refer To (if applicable) cry stale zipcpda <br />Monitodng hde acknoMetlg^enl ~ Well name or# Westminster C~ 60021 <br />Mhi-Riverbend ~ RI-MW01 Telephorne# <br /> <br />4. Location Of Pro osed Well (303) 657-4000 <br />cou^+y ', 9. Proposed Wefl Driller License # optional): <br />Weld SW ,/4p(fhe SE 1/4 10. Signature Of Well Owner, Consultant Or Authorized <br />Seniors ~ Tovmsnip NwS j Range Earw j PnntipalMendian A ent <br /> <br />19 I 1 ®^ ! 66 ^ ® ~ 6th The making of false statements herein constitutes perjury in the second <br />I , i degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S. <br /> 24-4 <br />104 <br />13 <br />I h <br />tl th <br />t <br />h <br />kn <br />ts <br />t <br />t <br />i <br />th <br />t <br /> - <br />ave rea <br />( <br />)(a). <br />e s <br />a <br />emen <br />ere <br />n, <br />ow <br />e con <br />en <br />s <br />Distance of well ttom senionlines(section lines are lypcelly not property lines) thereof and state that the are true tom knowled e. <br />105 FL from ^ N ®S 2 fi'20 Ft. from ®E ^ W Sign her ust ba onprnal si lure) i Dale <br /> -/ <br />For replacement wells only-distance and direction from old wek to new well ~ <br />~ 7~j( / <br />v <br />feet direction Pnnt name Sti~le <br /> 1 <br />, <br />WNl location adtlress (if applicable) 1 <br />~s .J, <br />C2 e'• ~ ~ /~-,~( ate 1 <br />! esa!/f~Z <br /> Office Use Only <br />Optional: GPS well location information in UTM format <br />You must check GPS unit for required settings as follows: USGS rep creme i DWR r0p no. i Surface elev. <br />Forret must be IITM <br />i <br />^ Zane t2 or ^ Zone 13 i <br />Easting Receipt oleo Only <br />Units must be Meters <br />i <br />Datum must be NAD83 ' <br />~ Northing <br />Unit must be set IO true north j ( <br />was GPS unit checked (a above? ^ vES ~ Remember to set Datum to NAD83 <br />5. Property Owner Information '. <br />Name of property owner i <br />Donald L and Suzanne Rittenhouse ' <br /> <br />Mailing adtlress I <br />~ <br />205 N PATIT RD I <br />City State Zip Code <br />Dayton WA 99328-8724 <br />Tnephone# <br />(509)382-1006 DIV_ WD_ BA_MD, <br />