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

-- A
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone - info: [phone] main: [phone]
Fax: [phone] htt://www.water.state.co.us
MONITORING/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
.-Name of wen owner -" - -----
Lafarge North America
10170 Church Ranch Road
Westminster
CO 180021
[phone]
D Use existing well
7 Construct new well
Other:
3. Refer To (if an
r Replacement for existing monitoring well:
Permit no.:
- -_.._._-..._ --------'
Mmitonng hole ackrawledgmen-t r-.-_am___e._o__.._._
Well nr #
MH- 048268 j TT-MW-02
4. Location Of Posed Well
County
;J? --- -?
Weld NW 1/4 of the SE 114
section { Township N or S Range _-?E or W -( pdndpal Meridian
34- 6N (- 66W i 16th
Distance of well from section fines (section lines are typically not property fines)
FL from NI S FL from E w
For repMacament wells only -distance and tlirectbn from old weU to new well
feet direction
Well location address (Include Ciy, State, Zqr) I- Check lf wen address is same asltem 1-----_
Optional: GPS well location information in UTM format _ -_--
You must check GPS unit for required settings as follows:
Format must be UfM
Zone 12 or Zone 13 `
Units must be Meters Easting 520157.92
Datum must be NAD83 1
Unit must be set to true north ! Northing 4476801.51
I
Was GPS unit checked for above? YES I Remember to set Datum to NAD83
5. Property owner Information
Name of property owner
rim D. and Jeanne Iverson
Mailing address
5011 F Street
City -- State Zip Code
.7reeley CO 80631
Telephone # -
[phone]
Office Use Only Form GWS-46 (1212007)
`DECEIVED
JAN 2 4 2009
6. Use Of Well
Use of this well is limited to monitoring water levels
and/or water quality sampling
7. Well Data (proposed)
Trial depth - -
--? Aqurfer
19.7 feet Allirvinl
8. Consultant Information (if applicable)
Name of contact person -----^--
Jeremy Deuto, PG
'--_--`---'-----.-.- --
Company name
Tetra Tech, Inc
Mailing address
1900 South Sunset Street
state Zip Code
_Longmont CO 80501
Telephone # -"
[phone]
9. Proposed Well Driller License # o tional :
10. Signature Of Well Owner, Consultant Or Authorized
_A ant
The making of false statements here_in constitutes u 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 they are true to Ty "owled ece..
perme (Must be s9'a'e2) Date
2fy? i l 13
Print name & Utle -'---- -'-----
f?nxJ , G/r?v1 X1/1 an ?r
Office Use Only
DWR map no. , Surface elev.
f ` Receipt area only
S4« S
I,
a, 19'7 45 Trans Number: 3636578 9
1/20/200910:09:15 AM
James Martin (19)
Total Trans Amt: $900.00
CHECK
Check Number: 1233090
DIV__L WDI^ BA_ MD