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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST, RM 818, DENVER, CO 80203 <br />phone - info: (303) 866-587 main: (303) 866-3581 <br />fax, (303) 866-3589 httpl/www.water.state.co.us <br />GENERAL PURPOSE <br />Water Well.Permit Application <br />Review instructions on reverse side prior to completing form. <br />The form must be completed In black or blue ink or typed. <br />Of <br />JUBILEE VENTURE. LLC <br />Centennial 'CO 80016 <br />Telephone # E-mail (optional) <br />tin'A) ri 7-nu-I <br />2. Type Of Application (check applicable boxes) <br />IM Construct new well 0 Change source (aquffer) <br />0 Replace existing well 0 Reapplication (expired permit) <br />0 Use existing well 0 COGCC well <br />0 Change or increase use 0 Other. <br />3. Refer To (if applicable) <br />Well permit # Water Courtcase # <br />/is 4? <br />Office Use Only <br />APR 12 2011 <br />"CfLt NEERS <br />WAT7ATERE <br />S. Use Of Well (check applicable boxes) <br />Attach a detailed description of uses applied for. <br />0 Industrial 0 Dewatering System <br />[I Municipal E] Geothermal ([] production or 0 reinjection) <br />0 Irrigation Other describe <br />0 Commercial ( )Placer Mining <br />7. Well Data (DrODosed) <br />rate ! Annual <br />9Pm , <br />acre-feet <br />75 feet 1 Wasatch fm. <br />8. Land On Which Ground Water Will Be Used I <br />Legal Description (may be provided as an attachment): <br />NE-14 and SE4, Sec. 2,_ T. 10 N., R. 92 , <br />6th PM, MOFFAT County; CO <br />4. Location Of Proposed Well Im ortantl See Instructions <br />ICounty I (f used for crop irrigation, attach a scaled map that shows <br />. # Acres I B. Omer <br />Moffat SE 114 of the NE 114 A <br />F <br />aeoson i h ownsmp n or s ) range E or W i Pnnapal Menman <br />2 I 10 6d 0 1 92 1111 I 6th <br />Distance of well from section lines (section lines are typically not property lines) <br />2000 FLfrom[R-NOS 1000 Fttrom@E0W <br />For replacement wells only - distance and direction from old web to new well <br />feet direction <br />Well location address (Include City. State. Zap) 0 Check if wall address is same as in hem 1. <br />E2 Sec. 2, T. 10 N., R. 92 W.., nth PM <br />Optional: GIPS well location information in UTM format You must check GPS unit for <br />required settings as follows: <br />Format must be UTM i <br />E3 zone 12 or[] Zone 13 I Easting <br />Units must be Meters <br />Datum must be NAD83 Northing <br />Unit must be set to true north <br />Was GPS unit checked for above? [] YES r Remember to set Datum to NAD93 <br />5. Parcel On Which Well Will Be Located <br />(YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) <br />A. Legal Description (maybe provided es an attachment): <br />E a Sec. 2, T. 10 N., R. 92 W., 6th PM <br />Colorado. Propprtv of the U.S. Gov't., <br />administered by the Bureau of Land <br />Mgmt., Little Snake River Field Office <br />Craig, Colorado. <br />B. # of acres in parcel C. owner <br />stN I ffLPf <br />?. W it this be the only well on this parcel? []YES [kO {if no -list other wells) -- <br />166789 (usable);16788, 018332-F, <br />State Parcel [DR (optional): pt - <br />I - <br />List any other wells or water rWMs used on this land <br />9. Proposed Well Driller License #(optional): <br />10. Signature Of Applicant(s) Or Authorized Agent <br />The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br />24-4-104 (13)(a). 1 have read the statements herein, know the contents <br />Print nna/am``/& title <br />/?ayfyle/ <br />/? 111;;a111 Z)? e?ll h.S /.rha iny <br />4- T <br />Office Use Only <br />USGS map name DWR map no. Surface elev." _ <br />area <br />Trans Nurat)sr: 3649842 <br />4112/20113:06:23 PEA <br />Laura Nelsen (7) <br />Total Trans Arfit $100.00 <br />C:REDI T CARD <br />Tender Arriount $100.00 <br />AouAMAP /G?7oy' -i?/o>L .;,:v?JCvoorp? <br />WE 1s" e_- e. r <br />WR <br />coca <br />TOPO <br />M"R <br />SOS - DIV WD BA MD