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] hftp://www.water.state.w.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 _..._ ............... _.._.............. _............... ....... _._........ _-................ ._.....
Exxon Mobil Corporation Use of this well is limited to monitoring water levels

....................... _._..... _............... _..... ._.._.._..----.---------- - --.._...... and/or water quality sampling
................ -..... ---
Mailing address
7. Well Data (proposed)

GSC-GP2-224, P.O. Box 2567 _......._........ --.--__............ .......... .....
Total depth i Aquifer
................ _.._........ _._................ ----.......... --..--...... .,........... _..._................ .
City State Zip code _._-_............ ----..
feet
176
- kDD UE
Houston TX 77252 8. Consultant Information (if applicable)
........_..._--._..____ _..._?_...._...._.-_._.__.-___.--_ .-._._._--------_.__
Telephone # 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.._....._._.....-...._. _...__.._..._.._..._.._.... - -- ---- -- ------ .............................__..._..._-....
Momtomn hole acknowledgment Well name
r
#
o/
5 9

._......_....___................... _.._._...._._..._........... _.... _.._ .............. _..... _._..... _.... _.............................. _................ _....... ...... _...--..............
.... _...................... ....................
MH- G
J
fi
,
I rV
tJ 1
Telephone #
4. Location Of Proposed Well (Importantl See Instructions) ( )
c°°"ty
9. Proposed Well Driller License # (optional): 53
'
NUJ 114 of the t5 W 1i4
Garfield ;
- -._.._..........._. _._......__......._._.._.._.
.. 10. Signature Of Well Owner Or Authorized Agent
..._.._-----
-
.
_...._.. - -..._.._ .._.__._.._..._.._....._.. -
Section Township N or S I Range E or -W- T Principal Meridian-- _...... -
_..._.__._...---- ......................------------ ---_............._..---..._.............. ._.-'--...... _-._...._...............__.............._...
The making of false statements herein constitutes perjury in the second

6 ?
i ?
`' qy ?P? degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
J
i 24-4-104 (13)(a). I have read the statements herein, know the contents
........... ......... ...... _.!_...__........... .._...... ............. _... __.._._---- -._.._.__._.__. thereof and state that they are true to my knowledge.
__............ _..
.

Distance of well from section lines
(section lines are typically not property lines)
Ft
from ? N PfS Ft
f
E W
°
_.__............. ...
.
....... _____...__ .................... _......___..__?_ ._ . _ _ ........
....
Sign here here (Must be or/g/nal signature) ! Date
.
.
rom
[/v ?1/ / !D l7 f
wells only -distance _- ...--_bo from well to ._..._........ _.. ---
For replacement wells only -distance and direction from old well to new well
-- -?? ------------- .__...._._...-...__._....._...__....._._.________. ................. ...... ......
Print name & 8 title
feet direction
.... __..._........ ...... _..... _ _........... _._...---__.._.__._....._.__.._..._ _---
Well location address (Include City
State
Zip) eck if well address is same as Item 1 - 1Z
(j v'n t" d ??i S - C0 "k c r v S O i?
,
,
.
Office Use Only
...
Optional: GPS well location information in UTM format USGSmap name DWRma .........
T P no. Surface elev.
You must check GPS unit for required settings as follows:
-...
. _
.
.... _................. _._... - ...._............. _........
Format must be UTM i

......................
Receipt area only
O Zone 12 or 0 Zone 13
Easting
Units must be Meters j j
Datum must be NAD83
i Northing
Unit must be set to true north j I
Was GPS unit checked for above? ? YES Remember to set Datum to NAD83
5. Property Owner Information
_...... _...._......... _ ........... .._..................... _..._.................. _...__..._..... _.__................... ---.................... _..... ........._._._................
_....__............. ............... __.._.
Name of property owner
j
Exxon Mobil Corporation
... ................................... .......................... _..-......................
....
.
........................ _................. _.._._._.... _.................................. _..._..................................... -............ _.... _............ .._..........
Mailing address

GSC-GP2-224, P.O. Box 2567 i .............. _.................................... _._._.............. ..... .... _..... _............................ _............. _...... _...._....................
_......................
.. ................ --- ........................................ _.................................. _...... _._.... _.............. _.... _...... __._.................................
City state Zip Code
Houston TX 77252
.. .................... ...._..__..._..... _....................... _................... --.--------..__............_........._.._.............. _........ _.......... _............ ___._..._.........
............... _.... ........... _..... _.._.
Telephone #
DIV WD BA MD
[phone]