2008-04-30_GENERAL DOCUMENTS - C1980001 (3)

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Form No. GWS-68 2~zoo5 EXISTING WELL INFORMATION AND INSPECTION FORM Division of Water Resources, 1313 Sherman St., Rm 818, Denver, CO 80203 PLEASE COMPLETE THIS FORM IN BLACK INK PERMIT NO: N/A RECEIPT NO: DIV: WD: Existing Well Location: SW'/4 of the SE'/4, Sec. 36, Twp 5 , Rng 86 , 6t'' Principal P.M. 1166 feet from N/S sec. line, 1664 feet from the E/W sec. line; County Routt Existing well owner: Name: John E. and Terry O. Redd Mailing Address: 7410 Sandy Lane City/State/Zip Mechanicsville/VA/23111 Telephone: (804) 746-7112 Description of parcel (subdivision, lot, blk, flg) Size 174.45 ac Existing well location and visual conditions: If stating no, please explain Type of Existing Well: Drilled, Hand Dug, Spring Well, Gallery Well, Gravel Pit, Other Drilled Distance to nearest septic tank/sewer line (approximate) Unknown feet Distance to nearest leach field (approximate) Unknown feet Is the well in a clean and sanitary location? Yes Is the well maintained in a clean and sanitary condition? Yes Is the ground at the surface sloped away from the well for proper drainage? Stick-Up Is the surface surrounding the well firm and stable? Yes Is the well situated in a well house or vault? No If so, is the well house or vault in good repair and condition? N/A Existing well construction and materials: If stating no, please explain Is the well equipped with a sanitary well seal/cap? Yes Is the well constructed with steel casing at the surface? Yes Does the casing extend at least one (1) foot above the surface? Yes Casing size 4 in; Estimated well depth 163 feet Who constructed well? Drilling Enterprises Inc. ;Who installed pump? N/A Current uses of existing well: Were the existing uses initiated prior to May 8, 1972? No Household use in single-family dwellings Watering of poultry and/or domestic animals Watering of livestock on farm or ranch; approximately how many head? Is this a feedlot? ;How many head? Lawn and/or garden square feet Crop Irrigation acres Fire Protection Commercial exempt for X Other: Monitoring Well Estimated date well constructed 11/17/79 ;Estimated date pump installed N/A Estimated date of first use Unknown ;Estimated flow rate N/A gpm How many other wells are located on this parcel? Unknown; Uses: Unknown; Permit/Case Nos.: N/A Existing Well Owner Signature: Date: For Office Use Only Has information above been verified? If not, please note accordingly. List any problems you have identified: (if none, please state so) Date of inspection: _ Inspected by (print): Phone Number _ (signed): Attach photo(s) if available or needed for further evaluation. Additional comments or information on back.