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

. _ - 16
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 c
phone - info: [phone] main: [phone]
Fax: [phone] httJ/www.water.state.co.us
MONITORING/OBSERVATION JAN 2 0 2009
Water Well Permit Application
'
Review instructions on reverse side prior to completing form.
A
EK Ft $OU
IN
The form must be completed in black or blue ink or typed. COLO
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
- - f
t
sly state zip code
ee
18.5
Alluvial

Westminster CO 80021 8. Consultant Information (if applicable) -_
Telephone It i E-Mail (Optical) Name of contact person
[phone] Jeremy Deuto, PG
-
2. Type Of Application (check applicable boxes) Comperiyname
vj Use existing well F- Replacement for existing monitoring well Tetra Tech, Inc
-I Construct new well
Permit no.: Maingaddress
Other. 1900 South Sunset Street
3. Refer To (if applicable) city -- - state Zip Code
Monitoring hole acknowledgment Wei name or# - Longmont CO 80501 _---
MH- 048267 TT-MW-04 Telephone #
4. Location Of Proposed Well [phone]
County 9. Proposed Well Driller License # o tional :
Weld NE 114 of the SE 114 10. Signature Of Well Owner, Consultant Or Authorized

section Township N or S Range E or W Principal Meridian ___LA gent

r
I 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.
know the contents
I have read the statements herein
24-4-104 (13)(a)
Distance of well from section lines (section lines are typically not property lines) ,
.
ther of and state that they are we to my knowledge_ -
Ft. from NJ S Fl. from E W Si h (Must be signs tu'e) Date
/
For replacement wells only - distance and direction from rid well to new well -
^- • 13, . 01
feet direction t name`s rile -

Well location address (Include City, state, Zip) F Check if well address is same asitem 1 `
c
Office Use Only
Optional: GPS well location information in UTM format
You must check GPS unit for required settings as follows: USG§ map name DwR map no. ! Surface elev.
Format must be UTM I I
I
Zone 12 or a zone 13 1
j
Easting 520435.7

.S F. SE Receipt area only
Units must be Meters
`f
t
1,311s
Datum must be NAD83 I Northing 4476729.8
Unit must be set to true north .3 E

Was GPS unit checked for above? YES Remember to set Datum to NAD83 1_ ' Cons P

5. Property Owner Information .
I I
_ & t
/
Trans Number: 3636678
1!24/200810:09:15 An
l
Nam of property owner y
! n i
James Martin (19)
City of Greeley, John Monson I t COt Total Trans Amt: $900.00
W
ili
dd ?yt m {} - CHECK
ress
a
ng a Check Number 1233090
1000 10th Street NO?(?
city State Zip Code
Greeley CO 80631
Telephone #
[phone] Dlv wo BA _ MD