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

is . . ._ .
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 '1=C:tVG
phone - info: [phone] main: [phone]
Fax: [phone] htt://www.water.state.co.us
MONITORING/OBSERVATION JAN 2 0 2009
Water Well Permit Application
Review instructions on reverse side prior to completing form. :3TfkTE ENGINEER
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
City Stale Zip code
ee
20.0
Alluvial

Westminster CO 180021 8. Consultant Information (if applicable)
----------
Telephone # E-Mail (Optional) Name of contact person
[phone]
Jeremy Deuto, PG
-- -?`---`
2. Type Of Application (check applicable boxes) Company name
-
orl Use existing well F- Replacement for existing monitoring well:
Tetra Tech, Inc
l Construct new well Permit no.: Nailing address
Other. 1900 South Sunset Street _
-?
3. Refer To (if applicable) city- -- state Zip Code
Monitoring hae aclaxw ledgrnent - wet name or Longmont CO 80501
MH- 048267 TT-MW-06 Telephone u
4. Location Of Proposed Well [phone]
-County 9. Proposed Well Driller License #(optional)-
Weld NE 1/4 Of the SE 1/4 10. Signature Of Well Owner, Consultant Or Authorized

Section Township N or S Range E or W Principal Meridian A ant

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.
know the contents
1 have read the statements herein
13
104
a)
244
--- ----
Distance of well from section lines (section lines are typically not property lines) ,
(
)(
.
-
e f and state that they are true to my knowledge_
th
_
Ft. from NJ S Fl. from E W Dat

For replacement wells only - distance and dire
ction from old well to new well
y
;E7
feet direction -
Wet location address (Include City, State. Zip) Check if well address is same asitem 1. Y\ /1 n G?
C.
_
_-
___ Office Use Only
_
.
_
Optional: GPS well location information in UTM torrnat
You must check GPS unit for required settings as follows: USGS map name DWR map no. i Surface Nev.
Format must be UTM ! r
Zone 12 or , Zone 13 i

Easting 520821.0 t S +
13 0`? Receipt area only
Units must be Meters
1
i ?o' r
Datum must be NAD83
i Northing 4476734.1 -
Unit must be set to true north i
Was GPS unit checked for above? YES Remember to set Datum to NAD83
8
5. Property Owner Information
--- - Trans Number: 363657
09
15 AM
1 /20!200910
Name of property owner :
:
James Martin (19)
City of Greeley, John Monson Total Trans Amt: $900.00
CHECK
Mailing address Check Number: 1233090
1000 10th Street Check Amourd..._ $900,0 Q.
City State Zip Code
Greeley CO 80631
Telephone # /
MD
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A
i
[phone] _
WD
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