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.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
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 Aquifer
:ry...~..__............. --.... _..--..----............... - - .--- .... _ .............................

j State Zip code

et
lD 9 -
B X200 ??
i
Houston TX 77252 8. Consultant Information (if applicable)

Telephone # - i E-Mail '(optional) ........ ......... -- -
Name of contact person
[phone] i
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
.................. _....... _.......... ...................._...._................ _.......... _..... _.___......... _................ -

.
._ name.. or _.#
Monitoring hole acknowledgment i...Well_
MH- q 9y& & w c c S a -._.._..... _............ _._.... _.......... _....... _........._.._ __..... _..._........... -_...... __.._ ...................... _..._.._._..---..................
_............. ........ __.._...............
Telephone #
4. Location Of Proposed Well (Important) See Instructions
.._......_............ --_._........... __..... _..._
........ .._.._...... _.... -....... -..... --..... _............ _..........__.
-C ( >
ounry
i
N 9. Proposed Well Driller License #(optional : ?,Y55'/
w 1/4 of the ?W 11
Garfield
: 10. Signature Of Well Owner Or Authorized Agent
.
_ ......................
_. ----- _._ ._ _... _ . - ......_._........._..__.._._..._ _
Section 1 Township or S 1 ._ ..Range E or W i Principal Meridian ....... -..... _.__................... ........ -.--_....... _.............................. -_...
The making of false statements herein constitutes perjury in the second
i
71
" Y6 ? 0 1 6
Q degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S.
-
om 24-4-104 (13)(a). I have read the statements herein, know the contents
- - --............ ~--- ......... --.............. --- -? --- ---- -?---

- ---- - - thereof and state that the are true tom knowledge
.

_..
Distance of well from section lines section lines are
( typically not property lines) _.__....__...._..
Sign n here (Must be original signature) Date
'Z100 Ft. from ? Nyf S b 9l Ft. from ? E;dW
--
lsjp.t??.?g_ ?
S ( t
t?
-............ _- - ............. _..... --......_._.... _....... _._........... _...... _.. -...__........ -- -_ ._...._..._...._.._..._.__..
For replacement wells only - distance and direction from old well to new well
_
-_.
Print ---- -- name - 8 -- title ------ -------- - - __-._.._.._.__...._....._..........- _.___._
....____.......
feet direction
Well location address (Include City, Slate, Zp) E6eck if well address is same as Item 1
.
Office Use Only

-._..------ -----.............---
_D_-_tlonal:--GPS .__.---w- --._..._..location._information.. ... ....._ ........._.__.__.....In---U T'- M--_form_.. at
pell
_..._....... --- --.... _ ._.-.._...- r.._._.....-----._._._.._..........
p name
USGS ma DWR ma
p no. f surface elev.
You must check GPS unit for required settings as follows:
i
.
_._.-.._..._....... -........ .._-................. _._.......__.._.__....._.-_.-
Format must be UTM ? ..._...----.:.........._......._.__....._.......--._...._...._.__._.....
;Receipt area only
? Zone 12 or 0 Zone 13
j Easting
Units must be Meters
Datum must be NAD83 '
Northing
Unit must be set to true north I
Was GPS unit ch
k
d f
b
? ? I
ec
e
or a
ove
YES i Remember to set Datum to NAD83
5. 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#

DIV WD BA MD
[phone]