2005-07-12_REVISION - M2000016 ‎(3)‎

• Permit No: M2000016
• IBM Index Class Name: Revision
• Doc Date: 7/12/2005
• Doc Name: adequacy review response
• From: lafarge north america
• To: dmg
• Type & Sequence: AM1
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES Office Use Only Form Gws-as (OV2o05)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone -info: [phone] main: [phone]
Fax: [phone] htt ://www.water.state.co.us
MONITORING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing forth.
The form must be completed in black or blue ink or typed.
1. Well Owner Information 6. Use Of Well
Name of well Owner
Lafarge West, Inc. Use of this well is limited to monitoring water levels
c!o Water Resource Specialist and/or water quality sampling
Mailing atldress 7. Well Data (proposed)
10170 Church Ranch Way, Suite 200 TWel eepN I Aqu;ser
Gty i state Zipcotle 31 feet !Alluvial
Westminster ! CO ; 80021 8. Consultant Information (if applicable)
Telephone # Name of wntact person
[phone] Water Resource Specialist
2. Type Of Application (check applicable boxes) Gonwanr name
® Use existing well ^ Replacement for existing monitoring well: Lafarge West, InC.
^ Construct new well permit no.: Mailing atlaress
^ other. 10170 Church Ranch Way, Suite 200
3. Refer To (if applicable) city state zip Code
Monitoring hde acknoMetlgment , WNl name or# Westminster CO 80021
Mtf-Riverbend RI-MW05 Telephone#

4. Location Of Pro osed Well [phone]
rA°^ry 9. Pro osed Well Driller License #(optional):
Weld NW „a of the NW +~a 10. Signature Of Well Owner, Consultant Or Authorized

Section i Township N or s ;. Range E or W I Pnndpal Mentlian A ent
19 ~ 1 ®^ ! ~
i 66 ^ ® 6th The making of false statements herein constitutes perjury in the second
degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S.
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Distance of well from section Ines (section lines are typically not property lines) thereof and state that the are We to m knowled e.
489 Ft. from ®N ^ S 1 ~61 Ft, hom ^ E ®W Sign h ust be original sig re) ; Date
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For replacement wells only-tlistanre antl tliredOn from Oltl well to new well ~+~ ~/../
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feet direction Print name 8 tine
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Walllorefionaddress (if applicable) _ '/
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C(Y~' , fR ~ Cyr- e~ cyc2 r Vr~
Office Use Only
Optional: GPS well location Information In IJTM format
You muat check GPS unit for required settings as follows: USGS map name i DWR rrep no. ~ Surface elev.
Fomat must be UTM I I
^ Zone 12 or ^ Zone 13 ;
I Fasting ;Receipt area only
Units rtust be Meters
Datum must be NAD&l
i NoAhing I
Unil must be set to We nonh
Was GPS unit checketl for above4 ^ YES ~ Remember to set Datum to NADa3
5. Property Owner Information
Narne of property owner -
1
Steven S McWilliams
i
Mailing atltlress
12236 W C R 8 1
City State Zip Cotle
Ft. Lupton CO 80621
Telephone #
[phone] DIV_ WD_ BA_ MD