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
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
Rim ........................_.........-........._._.............-- ----..... ........._............. ..----._...._......... ---......_.
e of well owner
Exxon Mobil Corporation
GSC-GP2-224, P.O. Box 2567
aii............. ............_................_.._._...........................__.._.__..-.._.-........_._..._.._......_
i State l i...........
code _
Houston TX i 77252
[phone]
2. Type Of Application (check applicable boxes)
-.._._..__.._.__....._._.__...._...._...- ---....._._..__._?..__.._.... ---
® Use existing well ? Replacement for existing monitoring well:
? Construct new well
Permit no.:
? Other:
3. Refer To (if applicable)
...... .......... ................... _.._........ _............ _.....__......_._......---...... ......_.__.._._....... _.._.._.......----_ .._._....__.............._----.........__.._
Monitoring[hhole acknowledgment I Well name or # r/
MH- ! I ??? L
4. Location Of Proposed Well (Importantl See Instructions;
County ..... _--............
-- -----
Garfield I NW 1/4 of the r 51,1 1t4
................._........__Township N" ................. or ........_.._....i....._... Rage . n.--- --E or ...... W _....._..,......-- Prin-d--pal.._...._._...-Meridian
---.._._.._
Section ? S ;
1
7 5 0? ! 9 5 0O j
....-_._........... _..... _..... _........... _.... 1._.... ---
Distance of well from section lines (section lines are typically not property lines) J
2 3 5 5 Ft. from ? N [? S J 1 f t Ft. from Q E ///?Q W
..__.._........._...........-_ .............. _..... _._._....._....... ..... _.......... ..... ......... _........... ........ _..___...._..._..""__....-._..`_.._._._
For replacement wells only - distance and direction from old well to new well
feet direction
....... _........ _.._._......... - - ..._...__...._._........ _.._.....
--
Well location address (Include city, State, Zip) Check if well address is same as Item 1.
Optional: GPS well location information in UTM format
You must check GPS unit for required settings as follows:
._........ __.......... ..... _.-..- -._.._.._._.............. _._......... _.........
...
Format must be UTM
? Zone 12 or ? Zone 13

Units must be Meters Easting
l
Datum must be NAD83
i
Northing
Un
t must be set to true north
Was GPS unit checked for above? ? YES I Remember to set Datum to NAD83
1
5. Property Owner Information
................................................... .
Name of p r opert y ..........................._._.
owner

...........
Exxon Mobil Corporation
.......................... ............................ _.......... _....................
.
.
............................................. _
Mailing address ................................................................................................. _..... __............ _......
GSC-GP2-224, P.O. Box 2567
..........- ............. _................ _....................... ......................... .
City ................ ............ --................ - .. _.. _...... _..... .... _......... _.............
State Zip Code
Houston TX 77252
Office Use
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)
_..... _.... _............ _..._........ - _...._..._.._-.....------------------ ........----._....-- --._...._........ ..
Total depth Aquifer ?
175 feet 1! 0- &&DUG
8. Consultant Information (if applicable)
Name of contact person
Company name
Mailing address
city
State Zip Code
Telephone #
9. Proposed Well Driller License #(optional): 53 /
10. Signature Of Well Owner Or Authorized Agent
...... _.... _.._............ _...---................ ........... _....... _-......... _....... _ ...................... _...... __._....... _.............. ....
.
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.
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge_
_ ------_.._.._ ..............--sign-
Sign h-ere (Must be original..ature) r- Date
f
.......... _?`'_."^ h- .--._......._........-- S. f : _t
Print name S title - -
1 alb L ?d-at5 Cloy S?.k?eIV (31-
Office Use Only
_....__ ............_...._..- ......__ ---- ._..... - ._..., _..._....._...._....... _ .............
USGS map.....n...ame.. j DWR map no. Surface elev.
area only
Telephone # -"?
DIV WD BA MD
[phone]