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~OLORADO DIVISION OF WATER RESOURCES <br />)EPARTMENT OF NATURAL RESOURCES <br />.313 SHERMAN ST., RM. 818, DENVER CO 80203 <br />thong -info: (3031 866-3587 main: 1303) 866-3581 <br />tAONITORtNGlOBSERVATION <br />Water Well Permit Application <br />Isviaw inatructiwnv to co form. <br />Must ba lotod in blade iJc or ad <br />1. APPLICANT INFORMATION 6. USE OF WELL <br />N'"'d'°w"" <br />H / , ~ mac. <br />o N~^'~ GROUND WATER SAMPLING (Quality) <br />MONITOR WATER LEVELS <br />O oTIIER• <br />~"°r'~' 7. WELL DATA <br />3 ~ ebo S~f'a-"~''~ ~ i~ ~y ~y / z0 Tar a~a, <br />5 7 rear ,b,~. <br />Fort Ff. es ~.MU fa.. <br />p" °e°' ~a0°' 8. CONSULTANT INFORMATION (a 'anaq <br />~lorea~e Co $/22.~ <br />T.ly4ti tw..~~mn iCowu..~d ~ T~.cr.ue/ ~.G. /t-5 rl Co. <br />~/9~ 78'f- /2.09 "°°"" /gLZO ~ Uovcr ue: <br />2. TYPE OF APPLICATION (check a itable bmc(es)) My N at r.+ e u fi GO $O (3 Z <br />Use adstlny wdl O Replaur~art tar - <br />O Construct new weU pemrt no. T"'d°iin0r°`Yi°'°0v°~ <br />t;7/9 .K6o - sys Z <br />~ Otlrcr: 9. PROPOSED WELL DRILLER to 'onall <br />3. REFER TO lit a 'cabin): atl"P""' "'"' "°°"'"""` <br />rya hol..ctno.wgm~ns • W.n nurse ar • <br />MH- 35582. MW -!0 10. SIGNATURE of ap licant(s1 or authorized a ant <br />4. LOCATION OF WELL The making of false statements herein r~stibAes perjtry <br />ewav L <br />~y¢,.aowfl auronly~rsr <br />5E jL Oyuoer <br />~1E 7f, In the SOaarld degree, wNch k puniahabla es a desa 1 mis- <br />demaanorpumvantfoC.RS.24+t-t04ft31fa). ihaveread <br />B~ctia. <br />' a~ ToVwr6ip M w 8 <br />1 9 O ~ ~W V~ E or W <br />(o S O NMra MwWn <br />(o ~ the Lt7ECllIemS hPfelfl. kIIOW Ula COfltlnt5 theraaf. and STaLe <br />that They are true to my knowledge. <br />ow,eo. of w«I hom r.oem uns <br />22.00 h from ~ N 0 S (~ h nem E O W rw.. »~~~ <br />~y` <br />wr 1raa.n.rw, n ~mmrrwn ~rera.rtr w.crro.r+ <br /> wisr~wcrr ~ <br />iw A~ wW wrp-6YiwN OnctlantRm ~q wr M r..r wM <br />feet direction 71tls °" <br />5. OWNERSHIP OtIFORMATION CoN3'~~+"N 1 S 9'"~ <br />watt owran wu¢ a rn..s a.A..rdw Sae the ravar89 side Of the farm for kntnrcdons, fee. a~ <br />information <br />"'0"" OPTIONAL INFORMATION <br /> asec w.r tiw. owa.w m. a.ae..r. <br />CRr sm >7a c.a. <br /> office u« oNr . <br />Twglirrs rrra.wa.aw <br />DIV <br />raorefnr owrra<rwE a an... ears reveal <br />CO <br />~~ <br />WD <br />oar sur ~coac <br />BA <br />r.wn«^~.. awa.wawa . <br />USE MD <br />Form GWS-4f, (l2l95) <br />