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-46 (02/2005)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone -info: [phone] main: [phone]
Fax: [phone] http://www.water.sfate.co.us
MONITORING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be completetl in black or blue ink or typed.
1. Well Owner Information 6. Use Of Well
Name orwen pWller
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 TOtaI depN I Aquifer
city state zDpode 30 feet Alluvial

Westminster i CO ~ 80021 8. Consultant Information (if applicable)
Telephone # Name of contatl person
[phone] Water Resource Specialist
2. Type Of Application (check applicable boxes) cprtpany nacre
® Use existing well ^ Replacement for existing monitoring well: Lafarge W eSt, InC.
^ ConsWct new well
Permit no.: Mailing address
^ other: 10170 Church Ranch Way, Suite 200
3. Refer To (if applicable) city state zipCOde
Monitoring hole acknowletlgment Well name or# Westminster CO 80021
MH-Riverbend ~ RI-MW07 Telepmone#

4. Location Of Pro osed Well [phone]
counq 9. Pro osed Well Driller License #(o tional):
Weld ~ SW vaoftne NW ,ra 10. Signature Of Well Owner, Consultant OrAuthoriied

S¢NOn 1 Township N or S Range E wW i Pdndpal Meridian A ent
`
19
1 ®^
66 ^ ® ~ 6th The making d false statements herein constitutes perjury in the secAnd
(
, degree, which is punishable as a Bass 1 misdemeanor pursuant to C.R.S.
24~
v
t
104
13
I h
d th
t
t
h
i
k
th
t
t
-
(
)(a).
a
e rea
e s
emen
s
ere
n,
now
e con
s
a
en
Distance W well from secton lines (section lines are rypicelly nW propertylines) thereof and state that the are true tom knowled e.
2335 Ft.,rom ®N ^ S 1288 Ft. from ^ E ®W Sign here (Must be oA9Na/ 9 nature) I Date/~j
For replacement wells only-distanx antl tlireclion from old well to new well ~ 7/j/~
feet direction Print~n~\ne &~title

Wa'I loptirn atldress (if applimde) ~t
( [-J P7'~U ~ ~~J ~ a^J~ ~aW~«
lG GG --
-
-
J
l`
`
ff
O
i
c
e
Use Only
Optional: GPS well location information in l1TM format
You must check GPS unit for requiretl settings as follows: USGS maD none ~ DwR map no. i Surtace elev.

Format must be UTM i
~
^ Zone 12 or ^ 2one,3 ~
i Easgng ~ Receipt area only

Units rtust be Meters I
Datum must be NADa] I
Northing
Unit must be set to bue north
Was GPS unit checked (a above? ^ VE3 i Remember to set Datum to NADa3
5. Property Owner Information
Name o(properry owner
Steven S McWilliams I
i
Mailing adorers I
I
12236 WCR 8
City State Zip Gode
Ft. Lupton CO 80621
Telephone #
[phone] DfV_ WD_ BA_ MD _