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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46 (02/2005) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM 818, DENVER CO 80203 <br />phone -info: (303) 866-3587 main: (303) 866-358 <br />Fax: (303 866-3589 htt ://www.watecstate.co.us <br />MONITORING/OBSERVATION <br />Water Weli 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 Well <br />Name gf well owner <br />Lafarge West, Inc. Use of this well is limited to monitoring water levels <br />c/o Water Resource Specialist and/or water quality sampling <br />Mailing address 7. Well Data (proposed) <br />10170 Church Ranch Way, Suite 200 Total tlepth I Aquifer <br />aty j start ~~ zrowtle 3g feet `plluvial <br /> <br />Westminster i CO ~ 80021 <br />I 8. Consultant Information (if applicable) <br />Telephone # Name of contact person <br />(303)657-4000 Water Resource Specialist <br />2. Type Of Application (check applicable boxes) c^^~^y^a^g <br />® Use existing well ^ Replacement for ezisGng monitoring well; Lafarge WBSt, InC. <br />^ Construct new well <br />Permit no.: Mailing atltlress <br />^ Other: 10170 Church Ranch Way, Suite 200 <br />3. Refer To (if applicable) cry state zip cptle <br />Monitoring hde acknowletlgment I Well name or# Westminster (.~ 80021 <br /> <br />MH-Riverbend I RI-MW03 relephpne# <br /> <br />4. Location Of Proposed Well (303) 657-4421 <br />~u^ry ! 9. Proposed Well Driller License #(optional): <br />Weld j NE 1/4 of the SW ,~n 10. Signature Of Well Owner, Consultant Or Authorized <br />saaion ~. TgwnsNp No<s Rangy EorW PnntipalMe^tlian A ent <br /> <br />19 ~ 1 ®^ ~ 66 ^ ® i 6th The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S. <br /> 24 <br />4 <br />104 <br />I h <br />t <br />13 <br />d <br />h <br />t <br />h <br />i <br />k <br />th <br />t <br />t <br /> - <br />- <br />( <br />ave rea <br />)(a). <br />t <br />e s <br />a <br />ements <br />ere <br />n, <br />now <br />e con <br />en <br />s <br />Distance o(well from section lines (section lines are typi®Ily not property lines) thereof and state that the are true tom knowled e. <br />1335 Ft. from ^ N [~ S 2631 Ft. from ^ E l~ W Sign here (Must original 'nature) I Date <br /> <br />For replacement wells oNy- Distance antl tlirecYion from ol0 well to new well ~ 7 8' <br />feet direction Pant nart,eslttta <br /> <br />Well locagon atltlress (if applicable) e~~t7 - <br />~ <br />` <br />~ ~u <br /> r <br />w/ <br />^ <br />rt <br /> Office Use Only <br />Optional: GPS well location information in IJTM format <br />You must check GPS unit for requiretl settings as follows: uSGS rnap name DWR map no. j Surface elev. <br />! <br />Fomat must be UTM i <br />^ zone 12 or ^ zone 13 i <br />j Easting Receipt area only <br />I <br />Units rtust be Meters <br />Datum must be NAD83 <br />Northing <br />Unit must be set to We nonh <br />~ <br />Was GPS unit checketl for above? ^ vE5 <br />! Remember to set Datum to NAD83 <br />5. Property Owner Information <br />Name or property owner <br />Donald L and Suzanne Rittenhouse j <br />Mailing atltlress ~ <br />205 N PATIT RD ~! <br />Ciry State Zip COde <br />Dayton CO 99328-8724 <br />Telephone # <br />(509)382-1006 DIV_ WD_ BA_ MD <br />