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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM. 818, DENVER CO 80203 <br />phone - info: (303) 866 -3587 maim: (303) 866 -3581 <br />MONITORING /OBSERVATION <br />Review instructions prior to completing form. <br />.Zoi»y <br />N M _ -�l <br />RECEIVED <br />FEB 19 1997 <br />WAi A )UR <br />RESiCES <br />STATE ENGINEER <br />COLO, <br />Water Well Permit Application <br />Must lye rsn,nrstsA 6n kl—.L : —t <br />1. APPLICANT INFORMATION <br />_____- �_ � —... .�.�.. •.. V.VM\ of tai t/r t",Q <br />6. USE OF WELL <br />Name at °PO``r" <br />Basin Resources, Inc. <br />CO GROUND WATER SAMPLING (quality) <br />l,B MONITOR WATER LEVELS <br />E3 OTHER - <br />'''`"0 Ad4rai <br />14300 Highway 12 <br />7. WELL DATA <br />coal depth I � <br />! + feet <br />l� <br />/' <br />city state zip wide <br />Weston CO. 81091 <br />8. CONSULTANT INFORMATION (optional) <br />'crud <br />Telepnor+a rvnber rirciuee wee nodal <br />( 719) 868 -2751 <br />` 2. TYPE OF APPLICATION (check applicable box(es)) <br />' S� Use existing well ❑Re pia cement for • - <br />❑ Construct new well permit no. <br />[i Other: <br />TO (if appl:cab, l4 <br />Takakrjne number IlnrJUde wee code) - - <br />9. ,PROPOSED WELL DRILLER (optional) <br />Company roma <br />I. <br />Monitoring hole acknowledgment 7 <br />MH- R <br />Well narre�or* <br />�?- ! <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 1 mis- <br />demeanor pursuant to C.R.S. 24- 4- 104(13)(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 />Les Animas <br />Quarter /quarter <br />SLJ Y4 <br />Quarter <br />Vtd % <br />Section Township N or s <br />7 3 3 Q <br />Range E or w <br />,f T Q E1' <br />Nimei" Meridian <br />Diinilne+ of well from section liner LL <br />`'?00 h. from E3 N 13 S 05-d ti, hnm Q E ew <br />Mus be irl aignatyre <br />Weil $ocstion oddrea, it di"Wen? horn applicant addMa 41 aopkk&bW <br />Prins name legNy <br />na, 6:- <br />For roplacemim well. oNy - d'irtmwe rrd direction honk eb WW to new well <br />feet direction <br />rda <br />eP1 <br />ta.a . <br />� /0 lf9 <br />5. OWNERSHIP INFORMATION <br />WELL OWFIM NAME re din.aru tfun applkamf <br />Self the rey4rse side of this #6rm for instructions, fee, and <br />advisory information <br />Addrew <br />. <br />OPTIONAL INFORMATION <br />USGS map memo <br />DWR n% -wno, <br />swfaee alev. <br />City Sate Zip Cade <br />Office Use Only <br />D1 V <br />CHECKS TR #411999 0-21997 %0.04- ' - <br />D11 CE OAHR RESWR ES 3 <br />_ BA <br />USE MD <br />Tafrylnrn no. (nvtWe tea cads) <br />PROPERTY owNEA NAME of diMere,t enan —a) <br />Addraas <br />/'f �G <br />zip Ci y st" <br />J�a•�� �,a�cc C� � g <br />Tarepnone no. lihclWa rs =dal <br />Form GWS-46 f 12/95) <br />