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1 <br />COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />Office Use Only Form GWS-4B (1112011) <br />1313 SHERMAN ST, Ste 921, DENVER CO U203 <br />Phone 303 868 -3581 Fax (303) 86&2223 dwrpgMdso ni COLAS <br />- <br />MONITORING/OBSERVATION <br />Water Well Permit Application <br />Revkm inabiwlions on reverse )tide prior to completing form <br />The form must be typed, eompiMed 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 />Holcim (US), Inc. <br />I <br />and/or water quality sampling <br />Lftliav - - <br />3500 Highway 120 <br />7. Well Data (proposed) <br />cily <br />Std <br />zip Code <br />Tdd CPU <br />AQ� <br />Florence <br />CO <br />81226 <br />57.4 lest <br />B. Consultant Information (ii applicable) <br />Tdaphonas <br />E-Mail tk NM or&* d r mnared) <br />meme or oondat po m <br />Christopher Krambis <br />719- 784 -1402 1 <br />2. Type Of Application (check applicable boxes) <br />❑ Use existing well ❑ Replacement for existing monitoring well <br />0 com f>ew Weil Permit no <br />❑ 091er <br />Company name <br />Golder Associates, Inc. <br />atuese <br />44 Union Blvd., Suite 300 <br />3. Refer To (d applicable) <br />Moolbmg hob aka madoment <br />WY name or tt <br />c iy side 2Q Code <br />MH- 051125 <br />MW -5 <br />Lakewood CO 80228 <br />4. Location Of Well Im rtantl See Instructions <br />Te'e"h" <br />303- 980 -0540 <br />cou* <br />Latimer <br />SW 114over NW 114 <br />9. PropMd Well Driller License o tional : <br />sewn <br />Township <br />NorS <br />Rang <br />Eorw <br />prno*MMendel <br />10. Name of Well Owner or Authorized Agent <br />8 <br />8 <br />x <br />I <br />69 <br />r <br />6th <br />I <br />The making of false statements herein constitutes perjury in the second <br />degree, wtoch its 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 = krxYMedge- <br />DWence dwell from aedtord ones laeceon Ire are timwW riot prop" Ines) <br />IPL tom K S Ft tam E W <br />sign or erMu hit name ham ? ^ Data (mm%d") <br />] f <br />.� f 02/2512013 <br />For mpleoane d waft ark - drmmnce aid atwelon tam dd well b new wan <br />feet dnvcb n <br />It equg grid name Not bee If corn then owner <br />Christopher Krambis, Jr., P.G. Senior Staff Hydrogeologtst <br />wel toraaon aadtaas (Wude cry, Sre, LP) ElChock0wel address in saer as item t <br />4629 North Overland Trail, Laport, CO 80535 <br />Office Use Only <br />Optional: GPS wield I w0mu lion in UTM format <br />USGS map name <br />DWR map no <br />sudaGe Slav <br />You must check GPS unit for mgL*W soUngs as follows <br />Fond must be UTM <br />Zone 12 or a zone 13 <br />Isds mull ee rlaten <br />F�hrxf 487365 <br />1 l � 2 ' r� 77 e ' <br />Receipt area only <br />Datum r' be widoss <br />Norlwng 4502982 <br />und must be ad to bus Rom <br />Was GPs um clrclyd tar mbm*7 ❑ YES <br />Remember to sat Dst xn to NW83 <br />Besl <br />Copy Available <br />5. Property Owner Information <br />Name of properly owner <br />Holcim (US), Inc. <br />--r' r,, i , )i.ii 1 O k 10 <br />3500 Highway 120 <br />U5,1 ill <br />ay <br />site <br />zn code <br />Florence <br />CO <br />81226 <br />raMphoir s <br />Div WD , BA MD <br />719 -784 -1402 <br />