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
Rime.
0 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

city sie ; Zip code ...... _............... - - .__._......._------ _...._.
_....__...... ._............ _..... ...... _....... _._............. - -- ....... _...... _._.
/D feet

Houston TX ! 77252 8. Consultant Information (if applicable)
Telephone # 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
Monitoring hole acknowledgment ; Well name or #
u q /
/
?
'r
?(

.
_........._.
- ---- --........... _._.._ ............................................. ........._...._.._........... _................ _.... _._._.
....._....-........._..........._...__...._.._.....__...
D
WW t
MH-
, l.. CLi
1 4J
1 Teeieplep
hone
#
4. Location Of Proposed Well (Important) See instructions) (
County

w
9. Proposed Well Driller License # o tional : Z'f 55/
va
Garfield %V W 1/4 of the
..... ._......... ... 10. Signature Of Well Owner Or Authorized Agent
._...._.._....
.

.... ...___._................... .-_._._..__...;.._......._9_..__........._.___ Prindpai-Meridian .._._._ _._-
Section Township N or S I Range E or W
7( ,
7 ...._
_........_.__..._._...._._..__.._._.....--
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
?
? ?
I J J ' ! J j lQ
? .
.
.
24-4-104 (13)(a). I have read the statements herein, know the contents
_ _.__....... L -_.-...... .... ..____-
.__._. thereof and state that they are true tomY. knowledge.
---- -.----.._.... _........ _-----..._............

Distance of well from section lines (sectio,n?llii,nn/es are typically not property lines) _,,,((

t ? ?l W
2 qV ? Ft. from[] NPS 077 Ft. from .._.._....._....---...... --.........
Sign here (Must be original siiggna?ture) I Date p
For replacement wells only - distance and direction from old well to new well 8 _tit._le __--__..........__..-...._...._.._..._._...________..._.-.... .................... _.... __...........___
Print name
feet direction (?
/ 44
(ON
k
s
h
Well location address (include City
Stais
Zi
) Id Check if well addre
s i
It
1 S `
AkAA
/L
o
,
,
p
s
s same as
em
.
Office Use Only

-_
_ .-........... _..--...... _................ _.._--_--....----.-..
Optional: GPS well-
_..loc. ation information in UTM format ----------.._..._..._.........---..._..._._....._.._._........_... ----......._....
USGS map name DWR map no. I Surface elev.
You must check GPS unit for required settings as follows:
_...._..... -- - _
___...... ---..._---..__............ -....... --, ---- ........................ __.......... -................. .... _......... --.- ..._........
Format must be UTM i ..... - ..._._._............. _....... ..._......... _.... .._........ __..._.............. _....... _........... _.... _.._.... .... --................. _.._.__.................
....
Receipt area only
17 Zone 12 or O Zone 13
E
I
asbng
Units must be Meters
Datum must be NAD83
Northing '
j
Unit must be set to true north I
I
Was GPS unit checked for above? ? YES j Remember to set Datum to NA083
5. Property Owner Information
...__.._....._.-_..... _.... .............. _......... - ............................
Name of -- -
property owner

I
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]