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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-a6 (ov2005) <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 htt :/7www.water.state.co.us <br />MONITORING/OBSERVATION <br />Water Well Permit Application <br />Review instructions on reverse side prior to eompletirtg form. <br />The form must be completed in black or blue ink or typed. <br />1. Well Owner Information 6. Use Of Well <br />Name o/ well owner <br />Lafarge West, Inc. ^^ <br />Use of this well is limited to monitoring water levels <br />c/o Water Resource Specialist and/or water quality sampling <br />Mailing seeress 7, Well Data (proposed) <br />10170 Church Ranch Way, Suite 200 rDtal aapm {'{ Aquifer <br />Giry slate ~ zipcoee 31 foot i Alluvial <br />I <br />Westminster ! CO 80021 <br />i 8. Consultant Information (if applicable) <br />TdeDhone # Name W contact person <br />(303)657-4000 Water Resource Specialist <br />2. Type Of Application (check applicable boxes) ~n~^y^~n~ <br />®Use existing well ^ Replacement for existing monitoring well: Lafarge West, InC. <br />^COnsWCt new well ~ <br />Permit no.: Mailing aaeress <br />^ orner: 10170 Church Ranch Way; Suite 200 <br />3. Refer To (if applicable) ciy state zipGoee <br />Monitoring hde admowletlgment j Wdl name or# Westminster CD 8021 <br />MFi-Riverbend j RI-MW02 Telephone# <br /> <br />4. Location Of Pro osed Well (303) 657-4421 <br />County 9. Pro sed Well Driller License #(optional): <br />Weld ~ SE vaatne SW +/< <br />, 10. Signature Of Well Owner, Consultant Or Authorized <br />' flange E or W I Ponopal Mentllan <br />Section Township Nor 5 A ent <br />I <br />19 ~ 1 ®^ ~ 66 ^ ® 6th The making of false statements herein constitutes perjury in the second <br /> degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br /> 243-104 (13 <br />ve re <br />) <br />I h <br />d th <br />tat <br />ment <br />herei <br />kn <br />w the <br />ntent <br />- )(a <br />. <br />a <br />a <br />e s <br />e <br />s <br />n, <br />o <br />co <br />s <br />Distance o(well fmm seoion lines (section lines are typically not proPeM lines) thereof and state that the are We to m knovAed e. <br />97 Ft. from ^ N ®S 1736 Ft. from ^ E ®W Sign here (Must be pripNal signet ) I Date <br />- <br />For repacemeni vrens Dory -eistance one eaetlion+rom ole well to new well ; 7`8` <br />feet direction Pnnt name rue <br /> <br /> <br />Well location atltlress (if applicable) / <br />2(rU ~ I ~~C (\ ~y/~°~ <br />~) <br /> Office Use Only <br />Optional: GPS well location information in UTM format <br />You must check GPS unit for requiretl settings as follows: USGS map name I DW R rrep no. Surtace elev. <br />Format must be UTM ~ <br />^ Zone 4 or ^ 2orre 13 . <br />Easting ;Receipt area only <br />Units must be Meters <br />I I <br />I <br />Datum must be NA083 I Northing i <br />Unit must be set to we noM i I <br />Was GPS unit chetketl for above? ^ YES !Remember to set Datum to NAD83 1 <br />5. Property Owner Information <br />Name of propeM owner <br />i <br />Donald L and Suzanne Rittenhouse <br />i <br />Mailing atlMess j <br />205 N PATIT RD <br />City State Zip Gotle <br />Dayton WA 99328-8724 <br />Telephone # <br />(509) 382-1006 DIV _ WD _ BA _ MD <br />