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Form No. <br />GWS-68 <br />2/2005 EXISTING WELL INFORMATION AND INSPECTION FORM <br />Division of Water Resources, 1313 Sherman St., Rm 818, Denver, CO 80203 <br />PLEASE COMPLETE THIS FORM IN BLACK INK <br />PERMIT NO: N/A RECEIPT NO: DIV: WD: <br />Existing Well Location: SW'/4 of the NE'/4, Sec. 36, Twp §, Rng L6, 61h Principal P.M. <br />2606 feet from N/S sec. line, 2502 feet from the E/W sec. line; County Routt <br />Existing well owner: Name: Maplewood Financial Inc. C/O William Dulan <br />Mailing Address: 3001 S. Lincoln Ave. <br />City/State/Zip Steamboat Springs /CO/80487 Telephone: (970) 879-8101 <br />Description of parcel (subdivision, lot, blk, flg) Size 265.37 ac <br />Existing well location and visual conditions: If stating no, please explain <br />Type of Existing Well: Drilled, Hand Dug, Spring Well, Gallery Well, Gravel Pit, Other Drilled <br />Distance to nearest septic tank/sewer line (approximate) Unknown feet <br />Distance to nearest leach field (approximate) Unknown feet <br />Is the well in a clean and sanitary location? Yes <br />Is the well maintained in a clean and sanitary condition? Yes <br />Is the ground at the surface sloped away from the well for proper drainage? Stick-Up <br />Is the surface surrounding the well firm and stable? Yes <br />Is the well situated in a well house or vault? No If so, is the well house or vault in good repair and <br />condition? N/A <br />Existing well construction and materials: If stating no, please explain <br />Is the well equipped with a sanitary well seal/cap? Yes <br />Is the well constructed with steel casing at the surface? PVC <br />Does the casing extend at least one (1) foot above the surface? Yes <br />Casing size 5 1 in; Estimated well depth 235. 164.3 feet <br />Who constructed well? Unknown ; Who installed pump? N/A <br />Current uses of existing well: Were the existing uses initiated prior to May 8, 1972? No <br />Household use in single-family dwellings <br />Watering of poultry and/or domestic animals <br />Watering of livestock on farm or ranch; approximately how many head? <br />Is this a feedlot? ; How many head? <br />Lawn and/or garden square feet <br />Crop Irrigation acres <br />Fire Protection <br />Commercial exempt for <br />X Other: Monitoring Well <br />Estimated date well constructed Unknown ; Estimated date pump installed N/A <br />Estimated date of first use Unknown ; Estimated flow rate N/A gpm <br />How many other wells are located on this parcel? Unknown; Uses: Unknown; <br />Permit/Case Nos.: N/A <br />Existina Well Owner Signature: <br />Date: <br />For Office Use Only <br />Has information above been verified? If not, please note accordingly. <br />List any problems you have identified: (if none, please state so) <br />Date of inspection: _ <br />Inspected by (print): <br />Phone Number <br />(signed): <br />Attach photo(s) if available or needed for further evaluation. Additional comments or information on back.