Laserfiche WebLink
Form No. <br />GV1lS68 <br />zrzoo5 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 />WELL NAME: TR-3 <br />Existing Well Location: SE'/4 of the NE'/4, Sec. 36, Twp §, Rng 16, 6th Principal P.M. <br />1445 feet from N/S sec. line, 89.8 feet from the ENV sec. line; County Routt <br />Existing well owner: Name: David and Marian Combs <br />Mailing Address: P. O. Box 772461 <br />City/State/Zip Steamboat Springs/CO/80477 Telephone: (970) 879-2235 <br />Description of parcel (subdivision, lot, blk, fig) Trs in N1/2 NE1/4, S1/2 NE1/4 Sec 36-5-86. Trs in NW1/4 <br />NW1/4 S1/2 NW1/4 N1/2 SW1/4 SW1/4 NE1/4 NW1/4 SE1/4 Sec 31-5-85 Total: 120.41 Acres <br />Existing we location an visual conditions: 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? Yes. PVC Casing in Metal Surface Completion <br />Does the casing extend at least one (1) foot above the surface? Yes <br />Casing size 4 in; Estimated well depth 15.5 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: Monitorinq Well <br />Estimated date well constructed 09/02/1979. 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 />Existing Well Owner or Consultant <br />Date: 91,3109 <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.