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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 main: (303) 866-3581 <br />ax: (3031866-3589 hfD: / /www.water.state.co.us <br />IONITORING/OBSERVATION <br />Water Well Permit Application <br />Review Instructions on reverse side prior to completing form. <br />The form must be completed in black or blue ink or typed. <br />1. Well Owner Information <br />Name of well owner <br />Sage Creek Coal Company, LLC <br />Mailing 'addrWss- <br />29515 Routt County Rd. #27 <br />CRY State <br />Zip code <br />Oak Creek CO 80467 <br />Telephone #-- <br />(970)870-2751 <br />.2. Type Of Application (check applicable boxes) <br />❑ Use existing well ❑ Replacement for existing monitoring well: <br />0 Construct new well Permit no.: <br />❑ Other: <br />3. Refer To (if applicable) <br />Monitoring hole acknowledgment i Well name <br />MH- ccu039mw <br />4. Location Of Proposed Well <br />County <br />'Outt SW 1/4 of the NW 1/4 <br />Section -1 : Township Nor -§--- F Range E or W T-Principal Meridian <br />32 1 6 0 El 87 ❑ 0 6th <br />Distance of well from section lines (section lines are typically not property lines) <br />1375 Ft from S N ❑ S 1080 Ft from ❑ E 0 W <br />For replacement wells only - distance and Tir;;ctior from well -t-o-i new -well <br />feet direction <br />Routt County Rd. 51 D <br />Optional: GPS well location information in UTM format <br />You must check GPS unit for required settings as follows: <br />Format must be UTM <br />❑ Zone 12 or 0 Zone 13 i <br />Easfing 315280.4 <br />Units must be Meters <br />Datum must be NA083 <br />Northing 4478605.5 <br />Unit must be set to true north <br />Was GPS unit checked for above? ED YES 1 Remember to set Datum to NAD83 <br />5. Property Owner Information <br />Name of property owner <br />20 Mile Sheep Company, LLC (John Maneotis) <br />Mailing address <br />35513 North Hwy 13 <br />ity State Zip Code <br />Craig CO 81625 <br />Telephone # <br />/07n\ A000 <br />Office Use Only I Form GWS-46 (02/2005) <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />and/or water quality sampling <br />7. Well Data (proposed) <br />TotaFaip—th — <br />- <br />1480 feet 1! Type 1 (confined) WE Ovbdn <br />8. Consultant Information (if applicable) <br />Name of contact person <br />Scott Cowman <br />Company name <br />Sage Creek Coal Company, LLC. <br />Mailing address <br />29515 Routt County Roa.d 27 -- ---- --------- - <br />City State Zip Code <br />Oak Creek-------- 80467 - — ------- <br />Telephone # <br />(970) 870-2751 <br />9. Proposed Well Driller License #(optional):#1448 <br />10. Signature Of Well Owner, Consultant Or Authorized <br />- Agent <br />The making of false statements herein constitutes perjury in the second <br />degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br />24-4-104 (13)(a). I have read the statements herein, know the contents <br />thereof and state that they are true to my knowled e. <br />Sign here (Must be original signature) Date <br />Print name & title <br />Office Use Only <br />map name i DWR map no i Surface elev <br />Receipt area only <br />DIV WD BA MD <br />