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LZ '/ "\ <br />' DO DIVISION OF WATER RESOUR <br />COL ~ REC,f IVED <br />k <br />R1~S:Re~. 76 ~ <br />1313 Sherman St., Denver, Colorado 80203 <br />618 Cente al Bldg. <br /> . <br />I A°p2~~ tr- <br />. <br /> P RMITAPPLICATION FORM <br /> ' <br />~~ <br />Application must -- ~. ~ <br />be complete where (((111 PERMIT TO USE GROUND WATER <br />C i, ,. <br />'w-;:0 <br />`=" _ <br />L f' <br />=L <br />applicable. Type or ' 1 A PERMIT TO CONSTRUCT A WELL <br />~ ^ • <br />print in BL ~` <br />~ ~ <br />P'~R: ( ) A PERMIT TO INSTALL A PUMP <br />~~ ~ ~ "•.fll <br />INK.No ov r \~S ;!!! O'_'~+°~ "l•fr~ <br />I T ~ <br />r ( I REPLACEMENT FOR N0. ~ <br />' ' <br />or erasu <br />e u ~ <br />;,_ PLi <br />?12 <br />initialed ( 1 OTHER -~ <br />. <br />~ , ~ rlil <br /> WATER COURT CASE N0. ~ • <br />I~_I <br />Lr <br />cLIG `J <br /> c <br />. <br />1) APPLICANT -mailing <br />NAME Gold Hill. Ventures <br />FOR OFFICE USE ONL <br />Receipt No. ry ~ / <br />STREET PO BOX 1523 I Basin <br />CITY Longmont CO 80501 <br />Israel Iz~ol <br />TELEPHONE NO. 449-7746 <br />(2) LOCATION OF PROPOSED WELL <br />County Boulder <br />SE '/. of the NW '!., Section 12 <br />7wp. 1 1d Rng. 72 I'T 6th P,M. <br />W,51 IE.W1 <br />(3) WATER USE AND WELL DATA <br />Proposed maximum pumping rate (gpm) Samples Only <br />Average annual amount of ground water <br />to be appropriated (acre feet): O <br />Number of acres to be irrigated: O <br />Proposed total depth Ifeet): 60 <br />AQUifer ground water is to be obtained from: <br />Granite <br />Owner's well designation ~ z <br />GROUND WATER TO BE USED FOR: <br />( )HOUSEHOLD USE ONLY <br />I )DOMESTIC (11 <br />( )LIVESTOCK (21 <br />( 1 COMMERCIAL (41 <br />no irrigation ID) <br />( )INDUSTRIAL (51 <br />( )IRRIGATION 161 <br />( )MUNICIPAL 18) <br />1 X) OTHER (91 Moni on ng <br />DETAIL 7HE USE ON BACK IN (11) <br />(4) DRILLER <br />Name GROUND l4ATER SYSTEMS, INC. <br />Street 4599 N. Broadway <br />C;ty Boulder. CO 80302 <br />(Stare) lZipl <br />Telephone No. 4 4 2- 4 0 8 3 Lic. No. °.6 3 <br />Dist. <br />CONDITIONS OF APPROVAL <br />This well shall be used in such a way as to cause <br />no material injury to existing water rights. The <br />issuance of the permit does not assure the applicant <br />that no injury will occur to another vested water <br />right or preclude another owner of a vested water <br />right from seeking relief in a civil court action. <br />1) APPROVED PURSUANT TO C.R.S. 37-90-137(2) TO <br />SATISFY THE PERMIT REQUIREMENTS OF C.R.S. <br />37-90-138(3). USE OF THIS WELL IS LIMITED TO <br />MONITORING WATER LEVELS AND/OR WATER QUALITY <br />SAMPLING. <br />2)_THIS WELL MUST BE EQUIPPED WITH A LOCKING <br />OR <br />AN OPEN WELL. <br />AT ALL TIMES <br />3) RECORDS OF WATER LEVEL MEASUREMENTS AND <br />WATER QUALITY ANALYSES SHALL BE MAINTAINED BY <br />THE WELL OWNER AND SUBMITTED TO THE DIVISION OF <br />4)TUPONCONCLUSIONOOF~HE MONITORING PROGRAM, <br />THE APPLICANT SHALL PLUG AND ABANDON IRIS WELL <br />IN ACCORDANCE WITH THF, RULES AND REGULATIONS <br />FOR WATER WELL CONSTRUCTION AND PUMP INSTALLA- <br />TION CONTRACTORS. <br />5) THE OWNER SHALL MARK THE WELL IN A CONSPICU- <br />OUS PLACE WITH APPROPRIATE WELL PERMIT NUMBER <br />AND NAME OF THE AQUIFER. HE SHALL TAKE <br />NECESSARY MEANS AND PRECAUTIONS TO PRESERVE <br />THESE MARKINGS. ~ 1'rt ~)~-j57 <br />APPLICATION APPROVED <br />PERMIT NUMBER 31662-M <br />DATE ISSUED SPR 221S8! <br />EXPIRATION DATE APR 2 3192x3 <br />BY <br />I D --- r .~ S rn~i•,T., <br />IN THIS COLUMN <br />