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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., Ste 821, DENVER CO 80203 <br />Phone: (303) 866 -3581 Fax (303) 866 -2223 dwrpermitsonlineCa�state co.us <br />Office Use Only <br />Form GWS -46 (11/2011) <br />MONITORING /OBSERVATION <br />Water Well Permit Application <br />Review instructions on reverse side prior to completing form. <br />The form must be typed, completed online or in black or blue ink. <br />1. Well Owner Information <br />Name of well owner <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />and /or water quality sampling <br />Mailing address <br />7. Well Data (proposed) <br />Total depth <br />feet <br />Aquifer <br />City <br />State <br />Zip code <br />8. Consultant Information (if applicable) <br />Telephone# <br />E- Mail (If <br />filing online it is required) <br />Name of contact person - <br />2. Type Of Application (check applicable boxes) <br />• Use existing well ❑ Replacement for existing monitoring well <br />❑ Construct new well Permit no • <br />• Other <br />Company name <br />Mailing address <br />3. Refer To (if applicable) <br />City <br />State <br />Zip Code <br />Monrtonng hole acknowledgment <br />MH- <br />Well name or # <br />Telephone# <br />4. Location Of Proposed Well (Important! See Instructions) <br />County <br />1/4 of the 1/4 <br />9. Proposed Well Driller License #(optional): <br />10. Name of Well Owner or Authorized Agent <br />Section <br />Township <br />N or S <br />f"- 1— <br />Range <br />E or W <br />i <br />Pnncipal Meridian <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 knowledge. <br />Distance of well from section lines section lines are typically not property lines) <br />Ft from! N r S Ft from r E i W <br />Sign or enter full name here <br />Date (mm/dd /yyyy) <br />For replacement wells only — distance and direction from old well to new well <br />feet direction <br />If signing print name Print title if other than land owner <br />Well location address (Include City, State, Zip) ❑ Check if well address is same as Item 1 <br />Office Use Only <br />Optional: GPS well location information in UTM format <br />You must check GPS unit for required settings as follows. <br />USGS map name <br />DWR map no <br />Surface elev <br />Format must be UTM <br />E Zone 12 or I' Zone 13 <br />Units must be Meters <br />Datum must be NAD83 <br />Unit must be set to true north <br />Was GPS unit checked for above II YES <br />Basting <br />Receipt area only <br />Northing <br />Remember to set Datum to NAD83 <br />5. Property Owner Information <br />Name of property owner <br />Mailing address <br />DIV WD BA MD <br />City <br />State <br />Zip Code <br />Telephone # <br />