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

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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 ^ ECEM0
phone - info: [phone] main: [phone]
Fax: [phone] htt•lhvww.water.state.co.us
MONITORING/OBSERVATION JAN 2 0 2009
Water Well Permit Application L/vRiEk kkSOURCES
Review Instructions on reverse side prior to completing form. :STATE ENGINEER
The form must be completed in black or blue ink or typed. COLA
1. Well Owner Information 6. Use Of Well
Nagle 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 dept, Aquifer

City sate zip code 31.4 feet Alluvial

Westminster ! CO 80021 8. Consultant Information (if applicable)
Telephone # E-tvaii (optional) Name of contact person
[phone] Jeremy Deuto, PG
2. Type of Application (check applicable boxes) Company name
Use existing well
? g (- Replacement for existing monitoring well: Tetra Tech, Inc
-1 Construct new well Permit no.: Meiling address
Other: 1900 South Sunset Street
3. Refer To (if applicable) City sate Zip code
Monitoring hole acknowledgment
; we" name or#
Longmont CO 80501
MH- 048268 i TT-MW-09 Telephone #
4. Location Of Proposed Well [phone]
County 9. Proposed Well Driller License # optional):
Weld NW 1/4 of the SE 114 10. Signature Of Well Owner, Consultant Or Authorized
section Township NorS Range Eor IN Principal Meridian _ - A ent _

34 - ?
6N 1-
66W 1
6th The making of false statements herein constitutes perjury in the second
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
- ---- I have read the statements herein
know the contents
244-104 (13)(a)
Distance of well tram section lines (section fines are typically not property lines) ,
.
Of and state _that the are true to mknowled9e.
-_?- -
Ft. from NJ S Ft. from E W gn h (Must be o al gnature) Date

For replacement wells only-distance and direction from old well to new well
- --?- ` -
feet direction Pnn drone&tie `
Well location address (Include City, State, Zip) F check if well address is same asltem 1. V) / llL l
-__..._-_.-.
_
?_..
_
_
_
. Office Use Only
-
_
__format _m-tat-
in..
GPS well
Optional:
information
UTM
-
You must check GPS unit for required settings as follows: j DWR map no. :Surface elev.
USES map name
Format must be l1TM
Zone 12 or Zone 13 `
Easting 519767.6
Ne! NW Receipt area only
Units must be Meters '
Datum must be 14Me3 !
Northing 4477537
6 n j
t ?/ ??
r
i
.
Unit must be set to he north 1 I rJ 9
l
Was GPS unit checked for above? YES Remember to set Datum to NADE3 -- 11
5
Pro
ert
Owner Inf
ti VL4 COOS • Trans Number
3636578
.
p
y
orma
on
- _- .
Name of property owner
-` -- - ?/ t?C
1 /I
) 1/20=910:09:15 AM
f James Martin (19)
Tim D. and Jeanne Iverson ca+e? Total Trans Amt: $900.00
CHECK
Mailing address
Q? m ^ Check Number: 1233090
5011 F Street
?
C e Check
City State Zip Code ??
'
Greeley_ CO 80631
Telephone At
[phone] DIV _j WD J?-? BA MD