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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHER14AN ST., RM. 818, DENVER CO 80203 <br />phone - info: (303) 866 -3587 main: (303) 866 -3581 <br />M ONITdRING /OBSERVATION <br />Review tnstnietiaris nriar fn mmnlatina fnrrn <br />AJ M `22 RECEIVED <br />FEB 19 1997 <br />;W/;P/d WATER <br />S �souAC�s <br />TATE EM(iWEEA <br />oow. <br />Water Well Permit Application <br />OR <br />1. APPLICANT INFORMATION <br />,y,u4e uv win latea in D{BCiC Ink or typec <br />6. USE OF WELL <br />"`" of e0O`""` <br />® GROUND WATER SAMPLING (quality) <br />0 MONITOR WATER LEVELS <br />Basin Resources, Inc. <br />13 OTHER: <br />'``°'°dn" <br />7. WELL DATA <br />14300 Highway 12 <br />Tow dwtn <br />7 <br />feet a� <br />t° <br />City U owe <br />S'' <br />8. CONSULTANT INFORMATION (optional) <br />Weston, CO. 81091 <br />Tele0mm a number Wsdude area eede) <br />(719) 868-2761 <br />„."P_PLICATION <br />_ <br />2. TYPE OF (Check applicable -box(es)) <br />C5 Use existing wr:; 0 Replacement for — <br />Teleprenenvi.Pw (imm- ,64 .,a ofte) <br />C Consvvct new well permit no. <br />- <br />❑ Owe;' <br />1 9. PROPOSED WELL WILLER (optional) <br />3. REFEfi ? : (if a tia; shit '' <br />F%R'• %• <br />A+oe�e number <br />Monitoring hole acknowledgment r <br />Well name or <br />MH- ,'�I�,�� <br />tj'�!� <br />10. SIGNATURE of applicant(s) or authorized agent <br />4. LOCATION OF WELL <br />The making of false statements herein cons hires perjury <br />in the second degree, which is punishable as a class 1 mis- <br />County <br />Quarter /Quarter <br />Quarter <br />Las Ani,inas <br />Pr %+ <br />vL(% % <br />demeanor pursuant to C.R.S. 24- 4- 104(13)(a). I have read <br />i the statements herein, know the contents thereof, and state <br />Section <br />S <br />h: <br />Town.p N or S <br />1 3731 5 ❑ <br />Range E or W <br />67W ❑ • <br />Principal INridi■n <br />1 <br />that they are true to my knowledge. <br />Oistaryiefe} of well from secttio(n lines <br />ei o <br />Muir be siy signature <br />ft. from 4�J N ❑ s 1100 ft. from ❑ E L`9 W <br />�j }/1 <br />well location addre.e• if differart from applicant eedreas Of aoolkable) . <br />y. <br />-9-12! <br />Prim legibly j//pp I <br />� "CNLr't„ , <br />For mplavetr,om yells on)y • dietenoe and direeoon from old well to new wail <br />T°° c.,. <br />P110joer io �py7 <br />IVA feet direction <br />5. OWNERSHIP INFORMATION <br />WELL OWNER NAME Of different trun apPliesM) %C <br />S e the re4erse side of form for instructions, fee, and <br />advis information <br />"ddrve <br />OPTIONAL INFORMATION <br />USGS map name <br />DWR mw <br />Surface elev. <br />City State Zv Code <br />Office Use Only <br />Telephone no. rmclude rea aodel <br />MV � "^ <br />PROPERTY OWNER NAME rrf dlfferem gun aooye) <br />john i,_ <br />co <br />DIEUS 04119x7)'021997 1440.1 <br />Addrer <br />DIV Orr WATER RESOURCES WD 1 <br />City State Dp Code <br />A <br />BA <br />irephone no. linah,ee rea pole) <br />USE MD <br />T;nrm r -WC _lA <br />