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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-4s (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) 866-3569 htt :ffw.vw.water.state.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 Well <br />Name of 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 atltlress 7. Well Data (proposed) <br />10170 Church Ranch Way, Suite 200 Total DepN ~ Aauifer <br />city ~ state , zipmtle <br />I I 35 feet I AIIUVIeI <br />I <br />Westminster CO j 80021 8. Consultant Information (if applicable) <br />Telephone # Name of mntatl person <br />(303)657-4000 Water Resource Specialist <br />2. Type Of Application (check applicable boxes) cprtpany name <br />® Use existing well ^ Replacement for existing monitoring well: Lafarge W25t, InC. <br />^ ConsWCt new well <br />Permit no.: Honing aatlreaa <br />^ other: 10170 Church Ranch Way, Suite 200 <br />3. Refer To (if applicable) ay state zlp COtle <br />Monitoring hole acknowletlgmen[ Well name w# Westminster CD $0021 <br />Mti-Riverbend ~ RI-MW04 Telephone# <br /> <br />4. Location Of Pro osed Well (303)657-4421 <br />cpuny 9. Proposed Well Driller License #(optional): <br />Weld NW i/<offhe SE ,r< 10. Signature Of Well Owner, Consultant Or Authorized <br /> <br />Section I Township Nors I Range EorW PrindpalMentllan Agent <br />I <br />19 01 ®^ 66 ^ ® <br />6th The making of false statements herein constitutes perjury in the second <br />1 degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S. <br /> 244 <br />104 (13) <br />a <br />I h <br />e <br />d th <br />st <br />t <br />th <br />t <br />t <br />h <br />i <br />k <br />t <br /> - <br />( <br />). <br />av <br />rea <br />a <br />emen <br />ere <br />n, <br />e <br />s <br />now <br />e con <br />en <br />s <br />Distance of well from section lines (section lines are typically not property lines) thereof and state that the are Vue tom knowed e. <br />2575 Ft. from ^ N ®S 2635 Ft. from ®E ^ W Sign here (Must De orBGra(v9na re) i Date <br /> <br />Fa replacement wens only-Distance ono D,rection from oltl well to new well 7 ~ ~.~ <br />feet direction Pnnt narre8tiae <br /> <br />Wetl location aoaress (rt applicaele) - L' (L <br />A.~ <br />C/~ ~P~/~" <br />~ <br /> rY <br />~~~ <br />~( <br />~7G/ OT <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 map name j DW R crap no. ~ Surtace elev. <br />Formal must be UTM j <br />^ Zone 12 or D Zone 13 I <br />Fasting i Receipt area only <br />Units rtusl De Meters <br />I <br />Datum must Da NADa3 ~I Nodhing <br />Unit must be set to We,wrth <br />Was GPS unit chetkeD /pr above? ^ YES ~ Remember to a¢t Datum to NADa3 <br />5. Property Owner Information j <br />Nacre of property owner I <br />Donald L and Suzanne Rittenhouse <br /> <br />Mailing atlCress I <br />j <br />205 N PATIT RD <br />City State Zip Cooe <br />Dayton WA 99328-8724 <br />Telephone ~ <br />(509)382-1006 DIV_ WD_ BA_ MD <br />