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COLORADO DIWSION OF WATER RESOURCES <br />DEPAR7t1ENT OF NATURAL RESOURCES <br />Office Use Only Form GWS46 (1112011) <br />1313 SFERKM ST., Sts 821, DENVER CO 80203 <br />-1 <br />Phone_ 303 866 -3581 Fax 303 866 -2223 oMrmitsonfinedlstzite co us <br />fl ��13 <br />MONITORINGJOSSERVATION <br />Water Well Permit Application <br />Rrtwlew kU&UCNMS on reverse skis PdW to ConrpNling tbrm. <br />The form must be typed, completed online or In black or blue ink. <br />1. Well Owner Information <br />No w ofviM caster <br />6. Use Of Well <br />Use of this well is limited to monitoring water levels <br />Holclm (US), Inc. <br />and/or water quality sampling <br />3500 Highway 120 <br />7. Well Data (proposed) <br />My <br />Sbswim <br />$ onda <br />To ol � <br />Agtilar <br />Florence <br />CO <br />81226 <br />229.7 feet <br />Td"h3m4 <br />E- Y (If flift orinattamciumd) <br />8. Consultant Information (if applicable) <br />Hama of conkai2 pomm <br />Christopher Krambis <br />719 -784 -1402 <br />2. Type Of Application (check applicable boxes) <br />❑ use existing well ❑ Replacement for exsting rronrtorxg well. <br />■ construct row well Permit no <br />❑Oliver <br />Comps'" ram <br />Golder Associates, Inc. <br />44 Union Blvd., Suite 300 <br />3. Refer To (if applicable) <br />Aib�bN� hots adnostedprtaM —I=- <br />nw ar N <br />cey <br />Stets <br />LD Coda <br />mH- 051126 <br />6 <br />Lakewood <br />CO <br />80228 <br />4. Location Of Propowswed Well (knportantl See Instructions <br />Tab ems <br />303- 980-0540 <br />co,rw <br />Larimer <br />SE u4 vane SW 1+4 <br />9. Proposed Well Driller License #(optional) <br />section <br />Teenetrtp <br />N or S <br />Ronp <br />E or W <br />P. rbrrdian <br />10. Name of Well Owner or Authorized Agent <br />8 <br />8 <br />x <br />69 <br />x <br />6th <br />The making of false statements harem constitutes perjury in the second <br />degree, which is punxshabie 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 fty are true hD my kraMedge <br />owe of aterr aam �� bw lsecson.� �� use) <br />FL bear N S Ft from E W <br />stun or &Mw M nofe hero <br />1 ' /� <br />Dab (rerodmM) <br />02/25/2013 <br />Fer nph*wn rrt wits or+r - dbbrtn and dwwen Feet dd..ex b aew weld <br />feet dwecum <br />ffMp* pMnsm. NrdM*odwHmwbndmww <br />Christopher Krambis, Jr.,P.G. Senior Staff Hydrogeobgist <br />woo mcabonaddeaa (bdtdeGYr.state,Zip) ew9+add1ftMxAamft8ten" <br />4629 North Overland Trail, L.aporL CO 80535 <br />Office Use Only <br />oplwnM: WS wM tecaben etfamakm in UTM brma <br />You roust check GPS wA for tegtied sedd�ps w fobws <br />USGS ntap name <br />OWR msp no <br />Staface ebv <br />Fomt l mar be UTM <br />Zama 12 or t• Zorn 13 <br />Enwv 487671 <br />% uJ <br />Receipt area only <br />unb rest be t bbta <br />D.r..,r..'be weoen <br />Nort v 4502021 <br />Una swat be oat b.ua nom, <br />Was GPS unt dtadnd br ebow' ❑ YES <br />Remember to set Dshm b NAD93 <br />; ',• J t -, S ' ,, <br />- <br />t,y <br />0 <br />O0 <br />5. Property Owner Information <br />Nam d prop" miner <br />Holcim (US), Inc. <br />`< 8 <br />Dsitr. -Y,tnr <br />t�it- <br />Iran ,.a +ion i ut.tl ,l0n ''ii, <br />utaer+omsea <br />3500 Highway 120 <br />!v <br />Cr <br />m <br />DN WD �3 BA MD <br />_ __ <br />Oty <br />Florence <br />s I <br />CO <br />zo cee. <br />81226 <br />Tebwhr t <br />719 - 784-1402 <br />