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T� <br />COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERIVAN ST., RM. 818, DENVER CO 80203 <br />phone - info: (303) 866 -3587 main: (303) 866 -3581 <br />MONITORING /OBSERVATION <br />t2&%AAW instructions Anr fn com letin form <br />.5p —12- <br />°P(;F)VFn <br />FEB 19 1997 <br />P7 i%U / ;0 wsTa��� s <br />soft <br />Water Well Permit Application <br />1. APPLICANT INFORMATION <br />Muni ue com iateti in black ink or tvmv ed <br />6. USE OF WELL <br />"""' of BOO`°" <br />Basin Resources, Inc. <br />W GROUND WATER SAMPLING (quality) <br />CP MONITOR WATER LEVELS <br />❑ OTHER: <br />"limp Address <br />14300 Highway 12 <br />7. WELL DATA <br />Tout a.am <br />436 fact <br />�� <br />12mFj, <br />city Si1e zipeede <br />Weston, CO. 8109 <br />S. CONSULTANT INFORMATION (optional) <br />Taiaphone rvmber firdude rw opdel <br />( 719) 868 -2 761 <br />Add+se <br />To4chom n""b" "' "'n <br />2 7Y PE 07 APPOr- A.TION ttheck applicable boxies)) <br />L 'Use existing well O ReV.scement for — <br />Construct rlew well permit no. <br />:-i �'l• °►: <br />Z' ! � a.– - czbltl <br />9. PROPOSED WELL DRILLER ;alTtianalt. _ <br />Company -.vn � <br />Monitoring hole acknowledgment i <br />MH- 61w, <br />Well name or / <br />F 330/ <br />10. SIGNATURE of applicant(s) or authorized agent <br />4. LOCATION OF WELL <br />The making of false statements herein constitutes perjury <br />in the second degree, which is punishable as a class t mis- <br />demeanor pursuant to C.R.S. 24- 4- 10403)(a). I have read <br />the statements herein, know the contents thereof, and state <br />that they are true to my knowledge. <br />county <br />LaS Animas <br />Quarter /quarter <br />:�E % <br />Quarter <br />6 L Y. <br />Section <br />S__3 <br />Towrishp Nor 5 <br />3 3 ❑ Ely <br />Range E or W <br />7 ❑ <br />Prir ipd Aitemidiam <br />Distance of well from section lines <br />Sb0 n from ❑ N [S X 00 ft. from ❑ E C(w <br />aigna tre <br />Mis;T41-24- <br />Well localion,addrwa. if different from applicant addreaa 6f anolieabicl <br />P"M name legibly <br />V — 0,-L/ <br />For replace e t wells eNy - diatarm and directon from old well to row well <br />feet direction <br />ra I.Pe rg pf Fed �� 9 <br />S. OWNERSHIP INFORMATION <br />WEiL OWNER NAME Of dmerera tr,.m apol giant) <br />See the everse side ofICIhis form for instructions, fee, and <br />sdvis information <br />Address; <br />OPTIONAL INFORMATION <br />USGS map memo <br />OWR rryno. <br />S.rfaer alay. <br />C" Starts Zlp Cede <br />Office Use Only <br />DIV <br />co <br />MEMO T114411949021997 1440.00Qr <br />DIV OF UATER RESON DES WD r] <br />$A <br />_ USE MD <br />T.ephone no. (include arm eodel <br />PROPERTY OWNER NAME fif different than above) <br />Addfew <br />City , zo code <br />7040 Is In. r�lude was code) <br />T_ —_ r..•rn .i rr w rnri <br />