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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) 866.3581 <br />Faz: (303 866-3589 h ://www.watecstate.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 fn 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 />MaillnB address 7. Well Data (proposed) <br />10170 Church Ranch Way, Suite 200 Tpral aepeN I Aquifer <br />City ~ State ~ Zip wtle 285 feet /~IIUVIaI <br />Westminster j CO ~ 80021 8. Consultant Information (if applicable) <br />Telephone # Name of contact person <br />(303)657-4000 Water Resource Specialist <br />2.7ype Of Application (check applicable boxes) Cortpanynarre <br />® Use existing well ^ Replacement for existing monitoring well: Lafarge West, InC. <br />^ Construct new well <br />Permit no.: Mooing address <br />Q other: 10170 Church Ranch Way, Suite 200 <br />3. Refer To (if applicable) city Sta1a zip code <br />Monitoring hde acknowledgment ~ Well name or# <br />I Westminster ~..0 60021 <br />Mtf-Riverbend ! RI-MW06 Teephone# <br /> <br />4. Location Of Proposed Well (303> 657-4421 <br />county ~ 9. Proposed Well Driller License #(optional <br />Weld ~ SW ,tn otthe NW 114 10. Signature Of Well Owner, Consultant Or Authorized <br />Setlion Township NorS I flange EorW ; PrinopalMentlian Agent <br />19 I 1 ®^ 66 ^ ® 16th The making of false statements herein constitutes perjury in the second <br />j degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S. <br /> 24-0 <br />104 <br />13 <br />I h <br />d th <br />t <br />t <br />h <br />i <br />- - <br />( <br />)(a). <br />ave rea <br />e s <br />a <br />ements <br />ere <br />n, know the contents <br />Distance of well from section lines (section lines are typically nol goperry lines) thereof and state that the are true tom knowled e. <br />1328 Ft. rrom ®N ~ S 1 ~ Ft. from ~ E ®W S,Bn here (Must De otletnal signature) ' Date <br /> pp <br />~ <br />Forreplacement wells only-distance antl tlirection from oltl well t0 new well ~ j 7(e <br />~ <br /> t <br />feet direction porn ,ina1 /'~ n ' <br />Well location atldress (it applicable) I_/e~~~. 1 /~~- ~ ~~C~~ //AA <br />k/ ///((( <br />Y/ <br /> se Only <br />Office U <br />Optional: GPS well location information in UTM format <br />You mu51 check GPS unit for required settings a5 follows: USGS rrep name DWR map no. Surtace Nev. <br />Format must be UTM ~ <br />i <br />^ Zone t2 or ^ Zone 13 <br />Fasting I Receipt area only <br />Units rtust be Maters I <br />Dawm must ba NADBI l <br />;Northing I <br />j <br />Unit must be set to true north <br />1 <br />Was GPS unit rliecked for above9 ^ vES ,j Remember to set Datum to NAD83 <br />5. Property Owner Information j <br />Name of property owner <br />Steven S McWilliams I <br />Mailing address i <br />12236 WCR 8 <br />Ciry State Lp Cede <br />Ft. Lupton CO 80621 <br />Teephone # <br />(303)654-0710 DN WD_ BA_ MD <br />