2011-05-19_HYDROLOGY - M1980047

• Permit No: M1980047
• IBM Index Class Name: HYDROLOGY
• Doc Date: 5/19/2011
• Doc Name: Form GWS-46
• From: Exxon Mobil
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-46 (07/2009)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone - info: [phone] main: [phone]
Fax: [phone] http://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

.............- -................ ........ _........-. ....
. _ ...... ...-- -- ........__.
?. _ _....._
. 6. Use Of Well

?. - ... _....._._._.._._....__......._..__._...._
....._..._
..
.
Name of well owner
Use of this well is limited to monitoring water levels
Exxon Mobil Corporation
.
... ---................. -- __. and/or water quality sampling
.
...............__........_.._................... ....._.__.-... _...._..._.
Mailing address 7. Well Data (proposed)
._...._.._........----............._........_........_....._...__....._--
GSC-GP2-224, P.O. Box 2567
_.._.._..... ..... _..__................. .... ..................... _.-......... r._._.._.....- ---..._._........_.._--._.._..........._........_..._....._.._........_..__..._.__..__-. ........
__.._............ --__................ -.--................. _--.._...... -....... _.. -- ._._....__..._.._
Total depthq ; Aquifer
1 feet
R
4KDO U E
Z
Gty State ip code IJ
Houston TX 77252 8. Consultant Information (if applicable)
-------- __.-.._....-----.._ ------------ ....--------- ......----....._........... _.......-
-
i.._..--...__............ _.
p ...._...... - - ..............._....._._._......__....__.... _..........._.. _.......__..._. _....._..._...
Tele hone # I E•Mail (Optional) ..
.....----
Name of contact person
[phone]
............ -..... .........._.._._.._....... -._-.._-..-.....-....__...._..........._......__.._
2. Type Of Application (check applicable boxes) company name
_------- _........... __.....__..._...._._._.._._._
® Use existing well ? Replacement for existing monitoring well:

_.
...--- ............... _....... _.._................. _..... ............... _............. .._...._._....-......... ---.... .._._................. ............................... _
----._..................................... _.......... _..........
? Construct new well Permit no.: Mailing address
? Other:
_ _..._....._._......... _._ ................ __._......... ..... _.._..... _..... _...................... -..... -....... _....... _...... -..................... _.... ._..................
__.... _..... _._.............. _...... _...... -
-
3. Refer To (if applicable)
........ _._.................. _..... ....... ---.................. _.... _.
..... city State Zip Code
.
- _.._ 9_.._.._....__._...........9 - - --._...........__ ............... ,-_.............. _......... _.__.
Momtorin hde acknowled ment Well name or #
MH- q1`161' i ? HA Telephone #
osed Well (Important! See Instructions)
ation Of Pro
4
L ( >
p
.
oc
_
County
9. Proposed Well Driller License # (optional): 53(
Garfield /V dU va of the 5 tQ 1/4 10. Signature Of Well Owner Or Authorized Agent
................. _.._...._..__...----... ---....------------- - ._..
Section ! Township ..... r S j Range -?E or W Principal M.ediar; -- -
r(?
a/
? ---- .....------._.._.._.
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.
5 ? 1 J ?fi
I 24-4-104 (13)(a). I have read the statements herein, know the contents
!
_ ............... __....... _.......... ._..... ;--.......... _..........._.................. - -.._._...._.._-._.....__.._.........-__..........._....._.............. _.._..... _..............
_.............. thereof and state that the are true tom knowled e
Distance of well from section lines (section lines are typically not property lines)
/
/ /
?
?
/
/
Ft
from [j E W
El N
S Sign here (Must be odglnal signature) Date
,p

,3/11
S-1
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.
ry
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7
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V Ft. from
y
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L W 1
W
.
....._......... ..._.._.... ........ ........._.... 1
i
.........._...__..._......__..__..._......._
.
..
.._ ........ ..... ......... __._.................--..__....._................. - - ............ ......._.__............._...__...
For replacement wells only -distance and direction from old well to new well
....
e ........._._..___..........__....._...__.._...__._........._....___.__......_..
nam..............e ..._. 8._ti.._tl.
Print

feet direction (??(

(/ Sid
t ?t? ?? S(t?t.l Su
....-..-
_.._._.__..._......_..__................_._.._....._.__........_......_.............._.._
Zip) (Check if well address is same as Item 1.
State
Well location address (Include City
,
, Office Use Only

_._...__...... __..._--- ........................... .._.................. _.._........... _............... .- ..... _...... _ ...._..._._.._........ ..__.... .......... __....... _....
_.._............ ............ _.._.........
Optional: GPS well location information in UTM format '. --............_........._._...-....._.._._.__............._.__...._......._ ..................... ..-- -.....D .................----
.................... ..............................................._.._.._..........
USGS map name j WR map no. Surf ace e..lev... .
! ;
You must check GPS unit for required settings as follows: I i
.._................... _ .......... .... _.__...
......-..
...
_..........._...._..... _.-_.... _.... _.......... ....... __...... ............. _.... _ ............... _._........ _..,.... ___............ --._................. __............ _.__._._.......
_.__.._...._........ _.......... .
Format must be UTM I _
......... ............. ......... .......
:
Receipt area only
? Zone 12 or 0 Zone 13
! Easting
Units must be Meters
Datum must be NAD83 i Northing
Unit must be set to true north
D83
was GPS unit checked for above? ? YES i Remember to set Datum to NA
S. Property Owner Information
... ..........--.-__ ............. _................ __............... _.... __...... __.... ...... _........ __.......
..
..._ .................._......--- _...
_
.
............ ---..._....._..._....
Name of property owner
Exxon Mobil Corporation
..................................... _........... _.......... ...... _-........ _...... __.._................. _-........................ ....... .....--._........ ............................
_...... -.....
Mailing address
!............. ................................. _._....... _............................... _...................... _..... ................................................................
-.........
GSC-GP2-224, P.O. Box 2567
............ _..._........ ._................ __................... _..
.
..
... ................ ..... _....... - -.......... _................. ......... ........................
City State Zip Code
Houston TX 77252
_.._ .............. -__....... ........ _.......... _..... ........... ..__......... _.... _....................... _..... _.__..... __........... _..._............... -.__._..........
_....... _.._.............. --........... -_.
Telephone#
DIWD BA MD
[phone]