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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46 (12/2007) <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 htt://www.water.state.co.us <br />MONITORING/OBSERVATION <br />Water Well Permit Application <br />Review instructions on reverse side prior to completing form. <br />The form must be completed in black or blue ink or typed. <br />1. Well Owner Information <br /> <br />............................................ ....._.................................................................... _._._...................... ..... _._..................... <br />...................... .. 6. Use Of Well <br /> <br /> <br />_...__....._-......._ <br />..............................................._.... _.................. ............ _........ .................. .................................. _...................... _.._....... <br /> _...... -...................................... ......... ....... <br />. . . . . Name . . . . . . . . . . ....................... . . .............. . ........................... <br />Name of well owner <br />John E. and Terry O. Redd <br />Use of this well is limited to monitoring water levels <br /> and/or water quality sampling <br />a.i.n9..address ......................................................................................................_................................................................................ <br />........_........_....__.............._.._......... 7. Well Data (proposed) <br /> <br /> <br />7410 andy Lane .......-...- ..............................................................-............-.?_.. -- - _..-.-.......- _ - <br /> <br />1 I p qui er <br />?Toa... .... A '1 <br />de th <br />y ................................. .......................................................................-..........................................-._..._.......................................... <br />................................................_._....._. <br />Cit State Zip code <br />145 feet I Unknown <br />Mechanicsville VA 23111 8. Consultant Information (if applicable) <br />.._.._.............. ..................................._......_._....................................._...............................................................-..............__.._...._....... <br />................................_.............._......_............_.... <br />..... .......... ...................... .................... ....................... .._................. ,............... ........... .__................................................. <br /> _..... _........................................................ _.... - <br />Telephone # E-Mail (Optional) <br />Name of contact person <br />(804)746-7112 N/A <br />........... ............. ................ .... ........... ........................................ _....... __.......................... ................ .............. ............... <br /> .................................................... _......... ..._............. ....................... <br />2. Type Of Application (check applicable boxes) Company name <br />........... .............................. ............ ............................. ....._............. _.._......... _..... ....................... ...._......................... <br />® Use existing well ? Replacement for existing monitoring well: <br />.... ...... _..... _ ....... ......... _....... .._............ _............. ...................... ...... ......... _......... _................... ................... ............................ <br />........... ........................... -...................................... ...-_. <br />? Construct new well <br />Permit no.:Not Permitted Mailing address <br />? Other: <br />............... - - .._...-.... _.... . <br />. <br /> . <br />..... _..... ................................... ................................. _......................... _.......... ................. ............... _....................... ... <br />Refer To (if applicable) <br />._..............................._...._...._..........................................................._..................................._....... <br />. <br />...................... ity State Zip Code <br />.. <br />....................9_...... ........,.,.........._..9.._.......__..__._....... <br />: <br />Monitorin hole acknowledgment i Well name or # <br />.... ....... .... ........................... ........ _............................. ........................ _........... ...-.................................._........ .................... <br />MH- N/A GMO-lp Telephone At <br />osed Well <br />Location Of Pro <br />4 ( ) <br />p <br />. <br />_ <br />.................. ..............._....................................- ............. ............................................. .......... _.._._...... <br />co?iy 9. Proposed Well Driller License #(o tiona :N/A <br />Routt SW 1/4 of the SE 1/4 <br />I 10. Signature Of Well Owner, Consultant Or Authorized <br />.................................................... . <br />.......................................................r...Townsh._.......... ......N.or_5.............r.....Range E or W r. .._.Principal fleridian ... ------- _ <br /> <br />Section I P I <br /> <br />ff <br />ent <br />A <br />......................... ..._.............................._..._.............. _...... ........ _............... ._....................... _............................. ........... <br /> .... ............................ _..__.._..__......_...... <br />The making of false statements herein constitutes perjury in the second <br />36 5 ®? 86 ? ® 6 degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br />.......... .................................................t.._......._..............._..._._...._............_..... ............. ............... ............... ........ ......... <br /> ......_....__.._i_........ _....._......_._.._._.._._........ ..__................ 24-4-104 (13)(a). I have read the statements herein, know the contents <br />Distance of well from section lines (section lines are typically not property lines) thereof and state that the are true tom knowled e. <br /> <br />........ <br />.......... _.... ....... _.............. _........ ............ _Y.............._....... ........ ....... ......... ...Y_...................... ........... 9._.......................... <br /> ................................................... <br />. <br />141 Ft. from El N ® S 1929 Ft. from ® E El W .... ....... .... .. <br />. <br />? ate <br />Sign here (Must be original signature) p <br />............................................................... ............................................. _.._......................... _...................... ..... ............................. <br />. . --........... ..._.............................. _. <br />For replacement wells only - distance and direction from old well to new well <br />i <br />............. ................. _....... .............. ..................... ......... _......................... ..;.................................... ........... _............... <br />_.. <br />N/A feet N/A direction <br />_ <br />....._.._....... . <br />_........_ ................. ..................................... .. <br />Print name & title <br />- - <br />. <br />..... .............. ................... .............................. ............. _........................................... ......................... .-.._............................. <br /> _............. _......._....._....... _...................... _......... <br />Well location address (Include City, State, Zip) ? Check if well address is same asltem 1. <br />N/A <br />.................. ........................................... _........ ............................... _.. <br />.. <br />. Office Use Only <br />.. <br />. <br />........... ................................ ..-...................... ................................ _..................................................................... ...... <br />Optional: GPS well location information in UTM format .................................................................................................................................. <br /> ........----............ .... --- •..................... .................. .... .......... ............ ....... _.... <br />USGS map name DWR map no. Surface elev. <br />You must check GPS unit for required settings as follows: I <br />..... _..._...--..__......... _.._..... _..... _ .............................. .................. ...._............... <br />Format must be UTM { -- ...._..... - - -........ ........ .............................................................................. <br />...._.................... ......... <br />? Zone 12 or ® Zone 13 <br />Easting 331653.65 ' Receipt area only <br />Units must be Meters <br />i <br />Datum must be NAD83 Northing 4467380.26 <br />Unit must be set to true north <br />Was GPS unit checked for above? l? YES Remember to set Datum to NAD83 <br />5. Property Owner Information <br />............................................... __...._............... ......................................................... _..................... ..... ............................. <br /> .................... ......... <br />Name of property owner <br />John E. and Terry O. Redd <br />..... ...................................... .......................... __.... ...................... ........................... ....... ............................ _........ ....--............. <br /> _................................. _....... _........... ................. <br />Mailing address <br />7410 Sandy Lane <br />........................................................................................_............ ....... _._ ................... _................................ _..._...... _...... <br /> _..................... _........................... _...... ........................ ._._..---...... ......... <br />.._..__. .. ............ <br />City State Zip Code <br />Mechanicsville VA 23111 <br />................................ _........ _.... _.._................ <br />. <br />.. <br />__ <br />.. <br />11 ..... ..................... ..... ............. ................................. _....... _................................. <br />Telephone # <br /> DIV WD BA MD <br />(804) 746-7112