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Form No. GWS-25 APPLICANT (303) 866-3581 OFFICE OF THE STATE ENGINEER COLORADO DIVISION OF WATER RESOURCES 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 1355 WELL PERMIT NUMBER 280845 _ DIV. 2 WD 12 DES. BASIN MD APPROVED WELL LOCATIOIN FREMONT COUNTY SE 1/4 SW 1/4 Section 16 HOLCIM US INC Township 19 S Range 68 W Sixth P.M. 3500 HWY 120 DISTANCES FROM SECTIO14 LINES, FLORENCE, CO 81226- 277 Ft. from South Section Line 1518 Ft. from West Section Line (719) 288-1427 UTM COORDINATES (Meters,Zone:13.NAD83) C44. Ao01Aa Kinrthinn• A9Aanna PERMIT TO GQN51 KUC I A wtLL ---° -- -- - ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT Page 1 of 2 CONDITIONS OF APPROVAL- 1) This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of this permit does not ensure that no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action. 2) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 18. 3) Approved pursuant to CRS 37-92-602(3)(b)(1) for uses as described in CRS 37-92-602(1)(0. Use of this well is limited to monitoring water levels and/or water quality sampling. This well is known as MWA 3. 4) This well must be equipped with a locking cap or seal to prevent well contamination or possible hazards as an open well. The well must be kept capped and locked at all times except during sampling or measuring. 5) Records of water level measurements and water quality analyses shall be maintained by the well owner and submitted to the Division of Water Resources upon request. 6) Upon conclusion of the monitoring program the well owner shall plug this well in accordance with Rule 1 El of the Water Well Construction Rules. A Well Abandonment Report must be completed and submitted to the Division of Water Resources within 60 days of plugging. 7) The owner shall mark the well In a conspicuous place with the well permit number and name of aquifer as appropriate, and shall take necessary means and precautions to preserve these markings. 8) This well must be constructed by or under the supervision of a licensed well driller or other authorized individual according to the Water Well Construction Rules. If non-standard construction is anticipated, a variance request must be submitted in accordance with Rule 18 and approved prior to well construction. 9) A Well Construction and Test Report (Form GWS-31), including lithologic log must be submitted by the individual authorized to construct the well. For non-standard construction, the report must include an as-built drawing showing details such as depth, casing, perforated zones, and a description of the grouting type and interval. 10) This well shall be constructed not more than 200 feet from the location specified on this permit. 11) Issuance of this permit does not guarantee that this well can be converted to a production well under a future permit. The ability of this well to be converted to a production well is limited by all governing statutes, rules, regulations, orders, and/or decrees. NOTE: This permit will expire on the expiration date unless the well is constructed by that date. A Well Construction and Test Report (GWS-31) must be submitted to the Division of Water Resources to verify the well has been constructed. An extension of the expiration date may be available. Contact the DWR for additional information or refer to the extension request form (GWS-64) available at: http:/Mww.'waterr.state.co.us/pubsiforms.asp APPROVED A J_ SMJ State Erigl er - - - By_ - - -. .. ... .,,...? , ,..