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
?ECEWM
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phone - info: [phone] main: [phone]

Fax: [phone] hftpJ/www.wate-r.state.co.us q
JAN 2 0 2009
MONITORING/OBSERVATION
Water Well Permit Application .'vAf'Ei 'SOURCES
STA
TE EGINEER
NEER
Review instructions on reverse side prior to completing form. COLO
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
Mailing address 7. Well Data (proposed)
10170 Church Ranch Road Total depth -? - - Aquifer

city -'- State -- zip code-" 20.5 feet Alluvial
Westminster CO 80021 8. Consultant Information (if applicable)
Telephone # E-Mail (Optional) Name of contact person
(303) 657000 Jeremy Deuto, PG
- ---'
2. Type Of Application (check applicable boxes) Company name
Use existing well F- Replacement for existing monitoring well: Tetra Tech, Inc
Construct new well Permit no.: Mailing address
Other: 1900 South Sunset Street
3. Refer To (if applicable) city state Zip Code
Monitoring hole acknowledgment Wei name or p
Longmont CO 80501
MH- 048267 TT-MW-05 Telephone #
4. Location Of Proposed Well [phone]
-
County ••1 ---------?- 9. Proposed Well Driller License # o tional):
Weld NE 114 of the SE 1/4 10. Signature Of Well Owner, Consultant Or Authorized
_
-
ection Township N or S Range
E or W
17 Principal Meridian A ent
i
the second
tit
t
h
i
[ r I n
n cons
u
es perjury
ere
The making of false statements
34 6N 6th
66W 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) th ,
.
f and state that the are true to in knowledge
Ft. from N I $ Ft. from E W 9n h (Must ba ginal ture) Date
of
43
--
For replacement wells only - distance and direction from rid well to new well -
t
I

feet direction t
Pdntna ie-&
j

Well location address (Include City, State, Zip) I- Check if well address is same asllem 1. et `
l
r r
f 1 , / /nJm /tm
------- --. __-• Office Use Only
Optional: GPS well location information in UTM format
You must check GPS unit for required settings as follows: USES map name DWR map no. I. Surface elev.
I
Format must be UTM
Zone 12 or , zone 13
Easting 520668.7
S ?t Receipt area only
Units must be Meters

Datum must be NAD83 I
t
I I .J
i Northing 4476729.9 t
Unit must be set to true north s p
S / .
Was GPS unit checked for above? YES Remember to set Datum to NAD83 r
A4
E
5. Property Owner Information
--
- Trans Number. 3636578
1 /20/2009 10:09:15 AM
Name of property owner
- - t??/ &I James Martin (19)
City of Greeley, John Monson coi-. Total Trans Amt: $900.00
Mailing address - ON rn ll CHECK
Check Number: 1233090
1000 10th Street

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o-}- I CP-
-.._.__,_
.-_Cheek Amount: __$900:00
Gty State Zip Code
Greeley CO 80631
Telephone #
MD
olv wo?+ BA
[phone]. _