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COLORADO DIVISION OF WATER RESOURCES <br />Office Use Only Form GV✓S -45 (04/2012) <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST, RM 821, DENVER, CO 80203 <br />Main: 303 866 -3581 Fax: 303 866 -2223 dwroermit nline state.co.us <br />GENERAL PURPOSE <br />Water Well Permit Application <br />Review instructions on reverse side prior to completing form. <br />The form must be computer generated, typed or in black or blue ink. <br />1. Applicant Information <br />g, Use Of Well check_applicable boxes) <br />pp Y <br />__`__ __ _____. <br />hlame of applicant <br />Attach a detailed description of uses applied for. <br />Western- FLlels- Colorado, LLC <br />-- <br />®Industrial 3] Dewatering System <br />Ma lingaddress- - - -- <br />P.O. Box 33424 <br />Municipal ❑ p ❑ Geothermal (production or reinjection) <br />__..__r— <br />City -' -stale _ 2iipcods- <br />Denver CO 180233 <br />Irrigation <br />M1 Other (describe): Dust suppression <br />❑ Commercial <br />Telephone # (area code & number)-_ E-mail (online filing required) <br />7. Well Data (proposed) <br />303 255 -5800 <br />Maximum pumping rate I Annual amount to be withdrawn <br />(In combination w/ <br />DW12 -1 & DW 12 -) 800 I See Attachment B acre -feet <br />Total depth Aquifer <br />2. Type Of Application applicable boxes <br />yp Pp ( check a pp ) <br />® Construct new well ❑ Use existing well <br />❑ Replace existing well ❑ Change or increase use <br />i <br />65 feet ,Bedrock /Coal <br />❑ Change source (aquifer) ❑ Reapplication (expired permit) <br />❑ <br />8, Land On Which Ground Water Will Be Used <br />COGCC Well ❑ Other: <br />Legal Description of Land (may be provided as an attachment). <br />3. Refer To (if applicable) <br />wellpermi# Walercouircasa# <br />West 1/2 of Section 25, Township 47 North, Range 16 West <br />N/A N/A <br />Designated aisin beternunaiion ?? i Well name or# <br />of the N.M. P.M. <br />DW12 -2 <br />4. Location Of Proposed Well <br />Cody <br />(If used for crop irrigation, attach a scaled map that shows irrigated area.) <br />Montrose SW 114 of the SW 114 <br />__ _ —_� ._- --- _ - - -- -- -- <br />A. #Aces B. Owner <br />_. __ —__ <br />section __ ._.... Township N or S Ringe" - E or W Pn upai Meodiaii"______ <br />i <br />25 <br />320 See Attachment A <br />— �__ .__ -- <br />C. List any other wens or water rights used on this land: <br />147 16 N. M <br />n _ " "- " ' ---Others <br />Distance of wall from section tines section lines are y pr pe y nes) <br />( typically not property lines) <br />wells and water rights operated under Case Nos. <br />738 Ft. from;— N IX; S 792 Fl. frorroE E, W <br />10CW208 and 09CW171 and related SWSP.s . <br />g, Proposed Well Driller License # o tional <br />p <br />_..-.. ._.._- _.-.__.. —_._. ___— _____. <br />For replacement wells only - distance and direction from old well to new well <br />10. Sign or Entered Name Of Applicant(s) Or Authorized Agent <br />feet direction <br />Well locsBonaddress (include city, state, Zip) � Check if well address is same as in Item '1- — - <br />___ _ __ - -_ _ —_—__ _ pe <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 />Optional: GPS well location information in UTM format You must check GPS unit for <br />thereof and state that they are true to my knowledge _ <br />Sign g application ; Date (mr(Vddtyyyy) <br />required settings as follows: <br />Format <br />Mi(i �or <br />must be UTM <br />Zone 12 orI( -•l Zone 13 <br />_ -_- - -.-.-.._ <br />If signing print name and title <br />Eastin <br />Units must be Meters I g <br />/f � /� � 14,4+- " n <br />l�Ltfl��G�tf N'ck0C�G. �Ct (.-,,ASu-6fJ�f �I�4 <br />Datum must be NAD83 Northing <br />Office Use Only <br />Unit must be set to true north <br />Was GPS unit checked for above? YES <br />❑ Remember to sat Datum to NAD83 <br />.._..._ ._.__ _. _._ .. <br />U SGS map name OVHR crap no. ! Surface elev. <br />i <br />5. Parcel On Which Well Will Be Located <br />(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) <br />�j Receipt area only <br />A. Legal Description (may be provided as an attachment): <br />West 1/2 of Section 25, Township 47 North, <br />Range 16 West of the N.M. P.M. <br />__._.._..__.__in <br />B. # of acres pa.....__ rcel C. Owner <br />AQUAMAP <br />320 See Attachment A <br />WE <br />D. Will this be the only well on this parcel? 0 YES NO (if no list other wells) <br />WR <br />Others wells operated under Case Nos. 10CW208 and <br />CWCB <br />09CW171 and related SWSPs. <br />ToPO <br />E. Slate Parcel to# (optional): <br />MYLAR <br />Sa5 DIV WD BA MD <br />