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CCLOR'.DO DIVISION OF W.~TER RESOURCES <br />DEP~IRTMENT OF NATURAL RESOURCES <br />1313 SHERbL4N ST., Rt. t. 8I8, DENVER CO 30203 i See attached SIYSP request, <br />phone -info: 1303) 866-3587 main: 13031866-3581 <br />GEiVERAL PURPOSE r Water Well Permit Application <br />(Please note: other rorms are available for specific uses including -residential, Lvestock, mon+[oring)observ., gravel pits, regavation of o!d wells) <br />Review instructions prior to completing form Must he completed in black ink or typed <br />1. APPLICANT INFORMATION 6. USE OF WELL (please attach detailed description) <br />Name Dt eDDecen` ~ INDUSTRIAL ^ OTHER: <br />lCeld (rOLlnt~' ^ COMMERCIAL <br />^ MUNICIPAL <br />Mulma nddrew ^ IRRIGATION <br />915 16th St. ^ FEED LOT -- number of head <br />7. WELL DATA <br />any sum zip eoae Mea~mvn punwnD m[. MnuN emoem <br />Greeley' CO 8Ub5' 1000 qpm 75 acre-feet <br />' Tool deem Ae,ubr <br />Telmnone numeu Itrclutle uee codel <br />(9;n) ass-aono <br />2. TYPE OF APPLICATION (check applicable boa(esll <br />© Construct new well <br />^ Replace existing well <br />^ Change (source) Aquifer <br />^ Other: <br />Water court case ~ <br />Emergency Verbal t <br />-VE- <br />Well name or 1 <br />^ Use existing well <br />^ Change or Increase Use <br />^ Reapplication lexpired pennitl <br />Permit b <br />Monitoring hale acknowledgment C <br />MH- <br />feet I Al1UU1 <br />USED <br />A. LEGAL DESCflIPTION (may be provided as an attachmentl: <br />Portions of 1~ ;, Shn--;, and.SE of Sec. 31, <br />Thu, R65L•/, 6th P.~f. and various roads <br />throughout A`eld COllllty <br />III usetl for amp irrigation, attach scaled map [hat shows imig ated areal <br />B. Y acres C. Owner <br />Z00 (Veld CClln t'~ <br />D. List any other well. or water dghte geed an this lend <br />9. <br />LDerue numaa <br />4. LOCATION OF WELL <br />County nuerter/quarter nuarter 10. SIGNATURE of applicantls) or authorized agent <br />lVe ld IUE [/. S1V y. The making of false statements herein constitutes perjury <br />Section <br />31 Towruhip N or S <br />b r~ ^ Ranpa E or W <br />ti5 ^ Ott Principal Meritlun <br />6 in the second degree, which is punishable as a class 1 mis- <br />demeanor pursuant to C.R.S. 2 4-4-1 0411 311a1. I have read <br />Distance of we+r rmm seocion lima <br />2580h from ^ N ©s <br />1390h Irom ^ E ©w the statements herein, know the contents thereof, and state <br />that they~re true to my knowledge. <br />louvon camas. <br />For nplwemen[ welb oNY - dmrce <br />hom old well [D now <br />5. TRACT ON WHICH WELL WILL BE LOCATED <br />A. LEGAL DESCflIPT10N (may he provided as an attaehmentl: <br />Slv~,, ~ SE', Sec. 51~, T 6N, R 651:', 6th P.)I. <br />(See attached map) <br />B. STATE PARCEL <br />ID.Y Ivpdonell: <br />C. a evw in tna D. Owns <br />?0(1 l+reld County <br />E. Will this be the only well on this tract? <br />19 YES ^ NO fit other wells are on this tract, see tl <br />applicant edtlrap Gf eppl,caDlel <br />OPTIONAL INFORM ION <br />usGS map name DwR map rD. surface dr. <br />2 3 13 <br />Office Use Only ~/0 ~~l <br />DIV <br />WD ~_ <br />BA <br />1 I USEISI MD <br />Form GWS-i5 (12195) <br />