2011-04-29_PERMIT FILE - M2011001 ‎(22)‎

• Permit No: M2011001
• IBM Index Class Name: PERMIT FILE
• Doc Date: 4/29/2011
• Doc Name: Adequacy Review Response- Att. 9- Well Permits
• From: Tetra Tech
• To: DRMS
• Media Type: D
• Archive: No

OLORADO
C
DIVISION OF
WATER
RESOURCES Office Use Only Form GWS 46 (12/2007)
DEPARTMENT
OF
NATURAL
RESOURCES
1313 SHERMAN ST., RIM 818, DENVER CO 80203
phone - info: [phone] main: [phone]
Fax: [phone] htt://www.water.state.co.us
MONITORING/OBSERVATION JAN 2 0 2009
Water Well Permit Application
Review instructions on reverse side prior to completing form. iVA(ER RF?SOURCES
The form must be completed in black or blue ink or typed. -.- E GINEER
Fit
1. Well Owner Information 6. Use Of Well
Name of well owner -..-_-....-.---------------.-----.-..._----
Use of this well is limited to monitoring water levels
Lafarge North America and/or water quality sampling
Mailing address 7. Well Data (proposed)
10170 Church Ranch Road Total depth --' - Aquifer

ckv ----------'--Tstate Zip code 22.9 feet Alluvial
Westminster j CO 80021 8. Consultant Information (if applicable)
Telephone # E-Mail (Optional) Name of contact person
(303) 65714000 Jeremy Deuto, PG
-2. Type Of Application (check applicable boxes) Company name
Use existing well F- Replacement for existing monitoring well: Tetra Tech, Inc -_ ^^- ---_ -- - _ -
-1 Construct new well Permit no : Mailing address
other: 1900 South Sunset Street
-
---- --- ---
3. Refer To (if applicable) state zip code
G+r ---
-
Monitoring tale acknowledgment Well name aft Longmont CO 80501
MH- 048264 TT-MW-01 Telephare At
4. Location
Of Proposed Well [phone]
..
County - - - 9. Proposed Well Driller License # citional :
Weld
-- SW 1/4 of the NW 74 10. Signature Of Well Owner, Consultant Or Authorized
Section Township N or S Range E or W Principal Meridian Agent _ _ _
The making of false statements herein constitutes perjury in the second
34
- --- 6N 66W ( 6th degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
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Distance of well from section lines (section lines are typically not property lines) and sta t theare true to my knowledge.
threor
Ft. from N J S Ft. from E W ere (Must la? origin Sig Date
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Fa replacement wells only -distance and direction trait rid welt to new well .
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feet direction .'
amthle--

Well location address (Include City, State, Zip) Check d well address is same asttem 1.
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Office Use Only
Optional: GPS well location information in UTM format
-
You must check GPS unit for required settings as follows: DwR map no. ; surface elev.
USGS map name-
Format must be UTM I .
-

Zone 12 or zone 13 Fasting 519972.6 _ --.-.---,_
-_
w E SW
Receipt area only
Units must be Meters ` .

Datum must be NM83 i
Northing 4476801.5 ?y
''L?O ", •S
' t
'
Unit must be set to true north ' ,
11 `7 W
Was GPS unit checked for above? YES Remember to set Datum to NAD83 + n
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` Trans Number: 3636578
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0091
Name of property owner 9j
Martin
Jarnes
Tim D. and Jeanne Iverson t Total Trans Amt: $900.00
n?t

Mailing address t

or, m ?{-11?1p{- CHECK

Ce , Check Number: 1233090
5011 F Street
--- Check Amount: $900.00
City
State Zip Code
Greeley CO 80631
Telephone # --- -
[phone] DIV __4_ WD1L BA MD