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<br /> <br />COLORADO DIVISION OF WATER RESOURCES Office Use Only - Form GWS-46 (02/2005) <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:/lwww.water.state.co.us _ <br />MONITORING/OBSERVATION _ <br /> <br />Water Wefi Permit Application _ <br />_ <br />- _.. <br />Review Instructions on reverse side prior to completing form. <br />The form must be completed in black or hlue ink or typed. <br />1. Well Owner Information 6. Use Of Well <br />Hayden Gulch Terminal, Inc. Use of this well is limited to monitoring water levels <br /> andlor water quality sampling <br />Mailing a0aress 7. Well Data (proposed) <br />701 Market Street, Suite 700 Tocal Depth Aquifer <br /> f <br />t i <br />cny ~ slate zipco0e ee <br />glluvium <br />12 5 <br /> <br />St. Louis MO 163101-1826 8. Consultant Information (if applicable) <br />Telephone * Nama b mntact person <br />(314)342-3400 John Weinman <br />2. Type Of Application (check applicable boxes) Company name <br />Q Use existing well ^ Replacement for existing monitoring welt: Hydro-EnVll'Or7ment8l SOIUttOnS, InC. <br />~ Construe! new well <br />Permit no.: Mailing ad9ess <br />^ Other. P.O. Box 772996 <br />3. Refer To (if applicable) city slate -p 000e <br />Manitonrg hale acknowlebgmant wen name or* Steamboat Springs CO 80477 <br />MH-45768 + HGDAL4 ' Yaiephane* <br /> <br />4. Location Of Pro osed Well (970) 871-6125 <br />county 9. Proposed Well Driller License #(opiional): <br />Routt NE uaotu,e NW +M 10. Signature Of Well Owner, Consultant Or Authorized <br /> <br />Section Tawnshlp N ar 5 ftarxla E or W Prinapel MaDGan A ent <br />23 6 ®Q 88 ^ ® 6th The making o4 false statements herein constitutes pery'ury in the second <br /> degree, which is punishable as a class 1 misdemeanor pursuant to C.R,S. <br /> 24-4-104 (13)(a) <br />I have read the statements herein <br />k <br />ow the <br />nt <br />t <br /> . <br />, <br />n <br />co <br />en <br />s <br />Diatarlce of well item aecJan 7inea (sac~nn lines are rypicauy,w! pepeM 1~~) thereof and state that the are true tom knowted~ e. <br />3~' S FI. from ^ $ 3 ~ I S R from ®E ^ W Sign here Must be Originar signaMe) Data <br />O r5 eG CW O` ,S O Jr~J 0' I CL Ca.J t <br />Fw replarament wells onty - 0istanra d Direction fmm 010 well to rte wan C ~--/ f Z 3 p L <br /> <br />feet direction Print 1{I We ~ 1 Y } <br />C 9.-JGnfYtrtM <br />KSrJ<~{ <br />~ <br />Well locatlw a0bre9a lrf applicable) n <br />, <br />~lO <br /> Office Use Only <br />Optional: GPS well bcation information In IJTTA format <br />You must Check GPS unit for requiretl settin93 as follows: USGS map name DWR map r0. Surface elev. <br />Format must 1» UTM F r <T U G <br />^ Zorro 12 w ^ Zone 13 Receipt area only <br /> Easbng k/k~ <br />Unib must be Meters <br />Datum must be NADaO <br />Northing <br />Unil must be set to Wa north ~~ ~P ~«~1~~ ~, <br />Was GPS unit mackeD fw above4 ^VE$ Remamher to set Datum to NAD83 <br />5. Property Owner Information ii3i;'cwo <br />- ice': 33:=iy <br /> ~ _ <br />' <br />Name of ProPeM Owner <br />/J.~l ~ ~. ~ f ai=iilEi <br />li; v <br />biiG,'v3 <br />Hockett Brother Farms _ <br /> v,ic_r 2ttfC:s=:x s <br />ii <br /> 9 <br />` <br />Mdlnl4,~ aDDre99 <br />P.O. Box 969 <br /> <br />Ciry State Zlp COtle <br />Hayden CO 81639 <br />Telephone g /_ ~ 7 <br />(970) 276-3267 DN_ wD_ 9A_ MD __ <br />