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 (1212007)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203 ????
phone - info: [phone] main: [phone]
Fax: [phone] hftp:/Avww.water.state.co.us

MONITORING/OBSERVATION JAN 2 0 2009
Water Well Permit Application N fER k-SOURCES
Review instructions on reverse side prior to completing form. STATE EGINEER
COLA
The form must be completed in black or blue ink or typed.
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
Mallirg adamss
7. Well Data (proposed)
-'-
10170 Church Ranch Road Total depth Aquifer

zip code 42.6 feet Alluvial

Westminster - CO
v- 80021 8. Consultant Information (if applicable)
-----------
Telephone #
; E-Mail (optionap Name of contact person
- ---
[phone] Jeremy Deuto, PG
2. Type Of Application (check applicable boxes) Canpanyname _-
1] 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 hole admovledgment i Well name or#
! Longmont CO 80501
MH- 048265
i TT-MW-08 Telephone # ___------_----_:•-
4. Location Of_P_r
oposed Well [phone]
_
County 9. Proposed Well Driller License #(o tional):
Weld NE 1/4 of the NE 114 10. Signature Of Well Owner, Consultant Or Authorized
Section Township N or S Range E a W' Pdndpal Meridian A ent

r
I The making of false statements herein constitutes perjury in the second
34 _ 6N 66W
16th degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.

Distance of well from section lines (section lines are typically not property lines) _
N 24-4-104 (13)(a). I have read the statements herein, know the contents
th f and state that the are true to my knowledge.
-
Ft. from
J S Ft. from E W Date

For repla cement wellsonly- aislance
and direction from old well to new well - -
j . /3,
gi5t
feet direction
Wed location atldress (Include City, Stale. Zip) Chk f well address is same - / //t ? / I /'
???444 r, ! V
- Office Use Only
Optional: GPS well location information in
UTM format
- -? - -
You must check GPS unit for required settings as follows: USGS map name
1 OWR map no. Surface elev.
Forma must be U1M
----- --
- - -
Zone 12 or r Zone 13

Units must he Meters Easting 520705.2 I
?' S? /? Receipt area only
Datum must be NADas E
Northing 4477768.0
Unit must be set to true north
Was GPS unit checked for above? YES I Remember to set Datum to NAD83 /f
5
Propert
Owner Inform
ti
.
y
a
on Trans Number: 3636578
Name of property owner - ----- - 1 /201200910:09:15 AM
James Martin (19)
Lafarge West, Inc David Jordan Total Trans Amt: $900.00
Hafting address CHECK
Check Number: 1233090
10170 Church Ranch Way
-
City
State Zip Code
Westminster CO 80021
Telephone #

[phone] //
DIV -t WD U BA- MD _