2009-09-17_GENERAL DOCUMENTS - C1980001

• Permit No: C1980001
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 9/17/2009
• Doc Name: Change in Ownership/Address
• From: WWC Engineering
• To: Office of State Engineer
• Permit Index Doc Type: Exploration
• Email Name: JDM
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46 (12/2007)
DEPARTMENT OF NATURAL RESOURCES -
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone - info: [phone] main: [phone]
Fax: [phone] http://www.water.state.co.us
MON(TQRING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be completed in black or blue ink or typed.
1. Well Owner Information
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.._...... _._._. 6. Use Of Well
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Name of well owner
Robert S. Dick and Kathryne E. Crawford .
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Use of this well is limited to monitoring water levels
and/or water quality sampling
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Mailing address ..._._.
7. Well Data (proposed)
P.O. Box 776236
City State I Zip code
Steamboat Springs CO 80477
[phone]
2. Type Of Application (check applicable boxes)
® Use existing well ? Replacement for existing monitoring well
? Construct new well Permit no.:Not Permitted
? Other:
3. Refer To (if applicable)
Monitonn hole acknowledgment Well name or #
MH- N/A TR-4
4. Location Of Proposed Well
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County ............................__.
Routt I NW 1/4 of the SW
I
_........... _ ............... _._ 1._................. - .P ........... ._._.....__......._ ._.__....9...... .......... _.......... i.............._ P ..__.......
Section I Townshi N or S Ran e E or W Princ al Me
30 ! 5 ®? 85 ? ® 6
>200 feet I Unknown
8. Consultant Information (if applicable)
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Name of contact person
Troy Summers
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Company name
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WWC Engineering
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Mailing address
611 Skyline Road
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City State Zip Code
Laramie WY -82070...._.
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Telephone #
[phone]
9. Proposed Well Driller License #(optional):N/A
114 10. Signature Of Well Owner, Consultant Or Authorized
Distance of well from section lines (section lines are typically not property lines)
1830 Ft. from ? N ® S 39.1 Ft. from ? E ® W
new
N/A feet N/A directiot*
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Well location address (Include City, State, Zip) ? Check if well address is same asltem 1.
Pt of Lots 7&14, Pt of Tr 162 Sec 30-5-85,Pt of Tr 162 Sec 31-5-85
Optional: GPS well location information in UTM format
You must check GPS unit for required settings as follows:
Format must be UTM
? Zone 12 or ® Zone 13 Easting 332288.55
Units must be Meters
Datum must be NAD83 Northing 4469552.15
Unit must be set to true north
Was GPS unit checked for above? ® YES Remember to set Datum to NAD83
5. Property Owner Information
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Name of property owner
Robert S. Dick and Kathryne E. Crawford
Mailing address
P.O. Box 776236
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City State Zip Code
Steamboat Springs CO 80477
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Telephone #
[phone]
The making of false statements herein constitutes perjury in the second
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state-thatthev are true to my knowledae.
9115109
aFname & title-
- 041 ?I?riFAT P u'o,%. •-W G100-?o c WT
Ffice Use Only
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GS map name I DWR map no.
area
DIV WD BA MD