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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45 (0712009) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST, RM 8118, DENVER, CO 80203 <br />phone -info: (303) 866-3587 main: (303) 866-3581 <br />GENERAL PURPOSE <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 />Karna of aPFtCWrf___ <br />Peabody Sage Creek Mining, LLC, <br />Ima, ling a 'dress <br />P3 Box 250 <br />city <br />relermome # <br />(9701276-7001 <br />2. Type Of Applicant <br />El Construct new well <br />D Replace existing well <br />El Use existing well <br />0 Change or increase use <br />3. Refer To (if applicat <br />shout permit is <br />i 'rAgnalel Basin Ntermination 0 <br />1 <br />Routt <br />ale Zip otido <br />CO 81639-0250 <br />6, Use Of Well (check applicable e <br />�!e Pg _s <br />Attach a oetalled description of uses applied for. <br />Industrial ❑ Dewatering System <br />Municipal 0 Geothermal (r_1 production or 0 relrijectio-i) <br />Irrigation <br />❑ Other (describe): <br />El Commercial <br />7. Well Data (proposed) <br />Annual any to tiewindivs-, <br />35 gpm 1 1.245 acre-feet <br />Ij Change source (aquifer) 730 ft I T I rout Ck Sandstone <br />[I Reapplication (expired permit) feet <br />0 COGCC well 8. Land On Which Ground Water Will Be Used <br />tXj Other: Refer to cover letter <br />Legal Description (may be provided asan avadwwty <br />Web name X a <br />Well (important! See <br />SW 114 of the SE 1!4 <br />-_ prinapalmoodian <br />oecbon I Townih.p N or 8 Ram <br />27 6N 87W p 6th <br />_Dstanoe olwell from seNon lines jsewon lines are typeftly not <br />200 F-t from ❑ N S 2,575 Ft. "im P-9 E El W <br />Far ieP4, ntweflit only- distance and direction from old well to nftw"li <br />feet direction <br />Check 0 .3 aaerass is sand es in Item 1, <br />Physical Address: 36600 Route County Road #27 <br />o_ptioneF _6PS W;lfwcaffori ­tnfQffnat-io--,-,-in-, 'U'- T­M-f—ormat You" must ­­check GP­S—unR for <br />required se"ings as follows. <br />Format must to! VTM <br />M zone 12 of W zone 13 Easting 318,953,8 <br />Units Must, be meteni <br />Datum rnuat bs NAM Northing 4,479,007.5 <br />Un t must be wl to rue north <br />Was GPS uric checked for above? MYES Remember to set Datum to NAD83 <br />5. Parcel On Which Well Will Be Located <br />_ffqU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)_ <br />A. Legal Description (maybe proAdeds3anariaOmnt) <br />SE4SW4, TR IN SW4SE4 SEC 27-6-87, <br />TRS IN NE4NW4 & NW4NE4 SEC 34-6-87 <br />TOTAL: 64.1 ACS <br />81 4 of acres pars* C. ciiwnitr <br />64 Sage Creek Holdings <br />—67 WO this be the only well on this parcel? AYES NNO, (if A-0, <br />Seneca Coal Well 5009 - Owned by Sage Ck Holdings <br />t, S41to Parcel to# (ojAonar, <br />939273002 <br />See Item 5 and attached map <br />(It used for crop jaqatiziri, anach a scaled map that shows irrigated aea,) <br />X #—Acres 8. Qvt�ar <br />N/A NIA <br />G. List any Other Wela or water rights Used Oil Cue Jamr!: <br />Seneca Coal Well 5009 S&y-* C-Ove'ur <br />9. Proposed Well Driller License #(option a [I: <br />10. Signature Of Applicant(s) Or Authorized Agent <br />The making of false statements herein constitutes perjury in 'he second <br />degree, which is punishable as a class I misdemeanor pursuant to C,R,S, <br />24-4-104 (13)(a). I have teed the statements herein, know the contents <br />thereof and state ghat they are true to my knowledge, <br />_W or! <br />4) <br />Dennis Jones - Hydrologist - Peabody investments CO, <br />Office Use Only <br />ils`GS_rra,p_ 'name &wk map �no Surface elev. <br />Receipt area only <br />AQUAMAP <br />WE <br />WR <br />CW08 <br />TOPO <br />MYLAR <br />S85 DIV- WD_ BA_ hill? _ <br />