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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHER.V,, ST., RM. 818, DENVER CO 80203 <br />phone - info-'(303) 866 -3587 main: (303) 866 -3581 <br />MONITQRING /OBSERVATION <br />RECEIVED <br />FEB 19 9991 <br />WATER <br />ATAM ENOlf+1EFq <br />LOCO. <br />Water Well Permit Application <br />rce%new tnsuucuu"zi pir wr w tour, ,aw, ,rrrrn- must De completed in black ink or eel <br />1. APPLICANT INFORMATION <br />6. USE OF WELL <br />Nome of aoo+ie.ti <br />Basin Resources, Inc. <br />® GROUND WATER SAMPLING (quality) <br />IN MONITOR WATER LEVELS <br />❑ OTHER: <br />Mailing Address <br />1Q300 Highway 12 <br />7. WELL DATA <br />Tool doom <br />6-10 feet <br />,�y„ti <br />44001 <br />c`" State zip ooda <br />Weston. CO. 810,91 <br />8. CONSULTANT INFORMATION (optional) <br />Toleotw manber lindtafa area erode► <br />( 719) 868-2761 <br />"ddreee <br />2. TYPE OF APPLICATION (check applicable box(es)) <br />Use existing well O Replacement for -- <br />0 Cfinstrut-t new well permit no. <br />L Ottler: <br />Tat-oh-re ri,"be<+lnd W ; ceder <br />a: PROPOSED WELL DRILLER (optional) . <br />: REFER TO (if applic-ihie): <br />COTi�a "y "t'e� !_� <br />L,e:�naentunOtr <br />Monitoring hole acknowledgment t <br />MH- AM <br />Weil name or i <br />8_1q <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 />Las Animas <br />Quarter /quarter <br />SLO Y. <br />Quarter <br />60 %. <br />Section <br />-7 <br />Towrafip Nor S <br />1 33 ❑ d <br />Range E or W <br />❑ d <br />Principal Meridian <br />C, <br />Distance of well from section tine�s, / �} <br />70C) ft. from ❑ N G- s / OO ft. from 'U' E ❑ W <br />Must oe 'foal ugneure <br />Well location addreaa. it different from oop.ko ,sad,. Of wolicable) <br />. <br />Pri legibly <br />For raptaoana'R wells only • d irtance and direvion from old wail to now wail <br />feet direction <br />Title <br />D.te <br />IF?7 <br />S. OWNERSHIP INFORMATION <br />'"ML01A/NER """tE Of °Htare"` eon a0°'Cif7L' <br />ee the r verse side of #&form for instructions, fee, and <br />advis= information <br />. <br />— <br />OPTIONAL INFORMATION <br />m <br />USGS moo nae <br />DWR mWno. <br />S.rram elev. <br />City State IP Code <br />Office Use Only <br />DIV <br />CHECKS TR #4li�r�� ?1497 0# 0..0 <br />DIV 61F DATER RES4►- IIECES <br />WD �- <br />BA <br />USE MD <br />Telephone no. rirtclude area code) <br />PROPERTY OWNER NAME Of different Ow wove! <br />We 6 P Wen <br />.,dare.. <br />city State Zip Code <br />Terapnone me. linch,da area eoaei <br />