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

DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER CO 80203
phone - info: [phone] main: [phone]
Fax: [phone] hftp:/twww.water.state.m.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
Name of well owner
Exxon Mobil Corporation
GSC-GP2-224, P.O. Box 2567
I Houston
[phone]
TX 77252
Use Only
Form GWS-46 (07/2009)
6. Use Of Well
Use of this well is limited to monitoring water levels
and/or water quality sampling
7. Well Data (proposed)
_....._._.._._._.... -.._-._..__........._....._..._....._......_............_........_..._.._..._....... --..... __.............................. _..._._._._.__...__..-_......_.......
Tot
al depth m 1 Aquifer 'r ?/
150 feet Au,mAL UALLf 1 -FILL
8. Consultant Information (if applicable)
Name of contac t person
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:
.......... _._.._ .............. _.... . ..._..._............. _............. -.............. _..--......................... -_.............. _.__............ _.._...__......--_---....-_--.....__.__
..................
City State Zip Code
3. Refer To (if applicable)
......................_.............................. -- - ---------._.._._.__...........-.....
Monitoring hole acknowledgment Well name or #
MH- 4S E ?' K .... _._.................... _..__ ................... _....... _...__.._......._.._...... _..... _._............ _............ _........ _....... _..--....................
_............. _._...... __.._.---.--.....................
Telephone #
4. Location Of Proposed Well (importantl See Instructions ( >
county j 9. Proposed Well Driller License # optional : 531
Garfield ,S W 1/4 of the S (.J 1/4 10. Signature Of Well Owner Or Authorized Agent
- ...._...; ._............_ ...........,.._........... _............. _........... --....... . .. _ ...... . . .; .. ....._.. _. __............................... _ . _.__._.. _..___.............
__...._....._..._.........._...._.... -- --.._............._...._.._................_._.....__.._.............
....... ...
Section Township Nor S Range . E or W Principal M than The making of false statements herein constitutes perjury in the second
vJ ? ,,( i 5 ? y! i -7 degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
1? YJ i ((/ 24-4-104 (13)(a). I have read the statements herein, know the contents
.................. i....__.._._....... _..... ___..........._._.-..__!.__._ ._. ..L_..... _................... _._.._........... ___---------- _ thereof and state that they are true
to my knowledge.
Distance of well from section lines (section lines are typically not property lines) Sign here (Must be orlglnal signature) ; Date
D & 7 Ft. from ? N as Ft. from ? E J0 W
_...._..._..... _.r....... . .............. ._._......_.._....._....... ._....._............ - -......_..._._._.._._._........_...._...._.?.+__..-........._.... -....... _.
For re lacement wells onl - distance and di - from W 11 t II
sl1, I01
p y re on rom o we o new we Print name S title r
feet direction ' (5 M ?QrNI S - cU\t7%ky V SQ
_.._........ ..... _........ _................ __..._..... __................. -................ ........ _....... ...._......._..._......._..._._..........__.__............__......._....__._._..._._
...../ t
Well location address (Include City, State, Zip) [Check if well address is same as Item 1.
Office Use Only
- ............._._...._......._.. _.............._...._.._._._..---..._...... - - -- --- --- -- ............... _--.... _........... ---.--.---.......................................
._.._.....,.................... _.... _............. _.... _.........
...
.._
__
.
-
- GPS. . .... well. _
. _loc... atio -n Inf.
Optional:.._.
.orma-ti _on_In._UT_M format USGS map name DWR map no. I Surface elev.
You must check GPS unit for required settings as follows:
_._...._.__...._....._........ _........ ... - ............... __.._........ ---................ _._._. _................ _........................ _............... _.... __..._..............
_.._..._......... _........
Format must be UTM
? Zone 12 or O Zone 13
! Easting
Units must be Meters I
Datum must be NAD83
Northing
Unit must be set to true north
i
Was GPS unit checked for above? ? YES 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 #
[phone]
Receipt area only
DIV WD BA MD