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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46 (OV2o06) <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) 866-3589 http://www.water.state.co.us <br />MONITORINGiOBSERVATION <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 o(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 atloress 7. Well Data (proposed) <br />10170 Church Ranch Way, Suite 200 Total °aptn I Aguirer <br />sty I state ; Lp Dade 30 feet ~ AIIUVial <br />Westminster ! CO { 80021 <br />i 8. Consultant Information (if applicable) <br />Teleptwce n Name a contact person <br />(303)657-4000 Water Resource Specialist <br />2. Type Of Application (check applicable boxes) Conpany name <br />® Use existing well ^ Replacement for existing monitoring well: Lafarge West, InC. <br />^ Construct new well Permit no.: Melling atltlress <br />^ other: 10170 Church Ranch Way, Suite 200 <br />3. Refer To (if applicable) ay state zip Cotle <br />Monitoring hde acknowledgment ~ well name prN Westminster CO 80021 <br />MH-Riverbend ; RI-MW08 Telephone# <br /> <br />4. Location Of Proposed Well (303) 657-4421 <br />cOen~ i 9. Proposed Well Driller License #(optional): <br />Weld SE 1l4otNe NW +~< 10. Signature Of Wetl Owner, Consultant Or Authorized <br />senior j Townsn;p Nas ;Range eww RnntlpalMeritlian Agent <br /> <br />24 I 1 ®^ , 67 ^ ~ <br />6th The making of false statements herein constitutes perjury in the second <br />~ <br />I degree, which is punishable as a dass 1 misdemeanor pursuant to C.R.S. <br />I 24-0 <br />104 <br />13 <br />d th <br />t <br />t <br />h <br />i <br />k <br />th <br />t <br />t <br />I h <br /> - <br />( <br />)(a). <br />ave rea <br />e sta <br />emen <br />s <br />ere <br />n, <br />now <br />e con <br />s <br />en <br />Distance of well from senior lines (seNon lines are tygrally not property lines) thefeof antl State that the are We to m knowled e. <br />2437 Ft. from ®N ^ S 1 ~ Ft. from ~ E ^ W Sign here (Must be original signature) ~ Date <br /> 1 <br />For replacement wells only- tlisWnce antl Oirecdon from oltl well to new well 7f~~ <br />feet direction Pnm ne shoe rt //'~/ <br />Weft (Oration atldress (d appGraDle) ~ <br />1 ~ _ ' \ /)/ <br />,~ , ~ <br /> ~ <br />~ L~ ~ ' <br />CYC/ C7 V~ <br />r l Q <br /> Offic@ USe Only <br />Optional: GPS well location information in UTM format <br />You must fheok GPS unit for fequiretl Settings a5 fDIlOwS: USGS map name . DWR map no. I sur/ace elev. <br />i <br />Fonrel must be UTM ~ I <br />^ zone lz or ~ zone l3 <br />Easting :Receipt area only <br />Unite must be Meters <br />I <br />Datum must be NAD85 <br />Nonhing ~ <br />Unit must be set to true north <br />t <br /> <br />Was GPS unit checked for above? ^ YES :Remember to set Datum to NAD83 i <br />i <br />5. Property Owner Information <br />Name of property owner I <br />Steven S McWilliams <br />Mailing atltlress I <br />I <br />12236 WCR 8 <br />City State Zip Cotle <br />Ft. Lupton CO 80621 <br />Televnone a <br />(303)654-0710 DIV_ WD_ BA_ MD <br />