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

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 ?,FCEIVED
phone - info: [phone] main: [phone]
Fax: [phone] h ://www.water.state.co.us
MONITORING/OBSERVATION JAN 2 0 2009
Water Well Permit Application I I
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Review instructions on reverse side
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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
-
City state I Z5p a 18.5 feet Alluvial
Westminster CO 180021 8. Consultant Information (if applicable) -
Telephone # i E-mail (Optional) Name of contact person
[phone] Jeremy Deuto, PG
2. Type Of Application (check applicable boxes) Company name
7] Use existing well r Replacement for existing monitoring well: - Tetra Tech, Inc
7 Construct new well Permit no.: Mailing address
Other: 1900 South Sunset Street
3. Refer To (if applicable) city -?- _ state Zip Code

-
Monitoring tale acknowledgment Well name a #..
Longmont CO 80501
-
MH- 048268 TT-MW-03 Telephone #
4. Location of Proposed Well [phone]
County ? 9. Proposed Well Driller License # o tional :
Weld NW 1/4 of the SE 74 10
Signature Of Well Owner
Consultant Or Authorized
,
.
Section Township N or S Range E or W
Principal Meridian _ A ant

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I The making of false statements herein constitutes perjury in the second
34 -- 6N 6th
66W degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
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_ e statemen
24-4-104 (13)(a). 1 have rea
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Distance of well from section lines (section lines are typically not properly lines) the of and state that theyare true to_Ty knowledge. _
Ft from NJ S Ft. from E W S h (Must be !n I sig
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For replacement wells only - distance and direction from did well to new well v"_111
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feet direction Print name & title

Well location address (Include City, State, Zip) I- Check if well address is same asltem 1. J /• ` ^
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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: USES map name ??
i DWR map no. Surface elev.
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Formal must be UTM
Zone 12 or , Zone 13

Fasting 520265.0
Units must be Meters _-?

1 )9 L, Receipt area only
Datum must be NAD83 9
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Northing 4476923.6
Unit must be set to true oath
Was GPS unit checked for above? YES Remember to set Datum to NAD83

5. Property Owner Information Trans Number. 3636578 C
Name of property owner _ 1/20/2009 10:09:15 AM
Tim D. and Jeanne Iverson James Martin
(19)
Total Trans Arm.
9 ,00
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Mailing address CHECK

5011 F Street Check Number: 1233090
Check Arnouf t: $900
00 ------
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City State Zip Code ,
-
Greeley CO 80631
Telephone #
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[phone] jjlV. wa. (vr
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