2009-11-06_GENERAL DOCUMENTS - C1983058

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COLORADO DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES 1313 SHERMAN ST:; RM 818; DENVER, CO 80203- phone - info: (303) 866-3587 main: (303) 866-3581 fax: (303) 866-3589 http://www.water.state.co.us I Office Use Only I Form GWS-44 (07/2009) RESIDENTIAL Note: Also use this form to apply for livestock watering Water Well Permit Application Review form instructions prior to completing form. The form must be completed in black or blue ink or typed. 1. Applicant Information Name of aDDlicant Mailing address Telephone # I E-mail (optional) 2. Type Of Application (check applicable boxes) ? Construct new well ? Change source (aquifer) ? Replace existing well ? Reapplication (expired permit) Use existing well ? Rooftop precip. collection ? Change or increase use ? Other: 3. Refer To (if applicable) Well permit # Water Courtcase # # I Well name or # 4. Location Of Proposed Well (Important! See Instructions county t, p Frenio it s6 1/4ofthe SIF 1/4 Section Township N or S Range E or W Principaidian 2[]N ?® T) ?? Distance of well from section lines (section lines are typically not property lines) j110 ® Ft. from ? N tai S /100 Ft. from X E0 W For replacement wells only - distance and direction from old well to new well feet direction Well location address (Include City, State, Zip) ? Check if well address is same as in Item 1. ir4rtje1a-& f iveAD4- well Optional: GPS well location information in UTM format. GPS unit settings are as follows: Format must be UTM ? Zone 12 or ? Zone 13 Easting: Units must be Meters Datum must be NAD83 Northing: Unit must be set to true north Was GPS unit checked for above? ? YES Remember to set Datum to NAD83 5. Parcel On Which Well Will Be Located (YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARC A. You must check and complete one of the following: ? Subdivision: Name Lot Block Filing/Unit ? County exemption (attach copy of county approval & survey): Name/# Lot # ? Parcel less than 35 acres, not in a subdivision, attach a deed with metes and bounds description recorded prior to June 1, 1972, and a current deed ? Mining claim (attach a copy of the deed or survey): Name/# CO Square 40 acre parcel as described in Item 4 ? Parcel of 35 or more acres (attach a metes and bounds description or survey) ? Other (attach metes & bounds description or survey and supporting documents) B. # of acres in parcel C. Are you the owner of this parcel? C/O, f. ®YES ? NO (if no - see instructions) D. Will this be the only well on this parcel? ®YES ? NO (if no - list other wells) AQUAMAP WE WR CWCB TOPO MYLAR SB5 6. Use Of Well (check applicable boxes See instructions to determine use(s) for which you may qualify ? A. Ordinary household use in one single-family dwelling (no outside use) ? B. Ordinary household use in 1 to 3 single-family dwellings: Number of dwellings: ? Home garden/lawn irrigation, not to exceed one acre: area irrigated ? sq. ft. ? acre ? Domestic animal watering - (non-commercial) C. Livestock watering (on farm/ranch/range/pasture) 7. Well Data (proposed) Maximum pumping rate Annual amount to be withdrawn /57 gpm acre-feet Total depth Aquifer 204) feet 55 Q Secm? 8. Water Supplier Is this parcel within boundaries of a water service area? ?YES NO If yes, provide name of supplier: 9. Type Of Sewage System ? Septic tank / absorption leach field ? Central system: District name: ? Vault: Location sewage to be hauled to: ? Other (attach copy of engineering design and report) 10. Proposed Well Driller License #(optional): 11. Signature Of Applicant(s) Or Authorized Agent 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 that the are true tom knowledge. Sign here (Must be original signature) Date I Print name & title Office Use Only USGS map name DWR map no. Surface elev. area DIV WD BA MD _