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

4

COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone - info: [phone] main: [phone]
Fax: [phone] htt://www.water.state.co.us
MONITORING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be completed in black or blue Ink or typed.
1. Well Owner Information
Name of well owner ------------
Lafarge North America
110170 Church Ranch Road
Westminster j CO 180021
[phone]
2. Type Of Application (check applicable boxes)
-71 Use existing well
I- Replacement for existing monitoring well:
-1 Construct new well Permit no.:
Other:
3. Refer To (if applicable)
_._..._...-.-_...----------- - ----'---- ? Well- --
Monitoring hole acknowledgment ynent name or # .... - - _ ...
MH- 048266 TT-MW-07
4. Location Of Proposed Well
- - •---'--_._ .
County
Form GWS-46 (12/2007)
a ECERAW
JAN 2 0 2009
6. Use Of Well
Use of this well is limited to monitoring water levels
and/or water quality sampling
7. Well Data (DrODOsed)
30.5 feet IAIIUVial
8. Consultant Information (if applicable)
-..._.- `-----..
Name of contact person
Jeremy Deuto, PG
Company name
Tetra Tech, Inc
Mailing address
1900 South Sunset Street
City State Zip Code
Lonqmont CO 80501
Telephone #
[phone]
9. Pro osed Well Driller License # o tional :
Weld SE 114ofthe NE 1/4 10. Signature Of Well Owner, Consultant Or Authorized
Section Township N or S Range E or W-- Principal Mendian A ent _ __ __ ___
6N The making of false statements herein constitutes perjury in the second
F I
34 66W - 6th degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
-- - 24-4-104 (13)(a). I have read the statements herein, know the contents
Distance of well from section lines (section lines are typically not property lines) _ eof and state that they are true to Ty knowledge.
Ft. from N I S Ft from E W ign re(Must be- rg arsignjture) Date
ror replacement wens only- distance and direction from old well to new well
feet direction Print name s titles
Well location address (include City, State, Zip) F- Check if well address is same asllem 1.
Office Use Only
Optional: GPS well location information in UTM format
You must check GPS unit for required settings as follows: USGs map name
Formal must be UTM
Zone 12 or o Zone 13

Units must be Meters Easting 520822.7
Datum must be NAD83
Northing 4477300.5
Unit must be set to true north i

Was GPS unit checked for above? I
YES I Remember to set Datum to NAD83
5. Propertv Owner Information
Name of property owner
City of Greeley, John Monson
Mailing address
1000 10th Street
City State Zip Code
Greeley_ CO 80631
Telephone #
[phone]
r I q O 'Al Receipt area only
171E
no.
-13.0v
Trans plumber: 3636578 V
1/20r"O 10:09:15 AM
James Martin (19)
TOW Tram Amt: $900.00
CHECK
Check Number: 1233090
DIV--I- WD GJ BA MD