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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTNWMT OF NATURAL RESOURCES <br />Office Use Only Form GWS-46 (11/2011) <br />1313 SFERMAN ST, Ste 821, DENVER CO 80203 <br />Phone 303 886.3581 Fax 303 888.2223 ftWrrriWnljngQstate co <br />MONITORINGIOBSERVATION <br />Water Well Permit Application <br />Review insbudions on reverse slde prier to completing form. <br />The form must be typed, completied online or In black or blue ink. <br />r <br />1. Well Owner Information <br />Nom of OW] amar <br />G. Use of Well <br />Use of this well is limited to monitoring water levels <br />Holcim (US), Inc. <br />and/or water quality sampling <br />it,& a,. <br />3500 Highway 120 <br />T. Well Data (proposed) <br />C,Ky <br />sum <br />MP Cade <br />al d <br />Triepth <br />Awft <br />Florence <br />CO <br />81226 <br />259.2 feet <br />8. Consultant Information (if applicable) <br />Tdephono0 <br />E- MaN(rtsrnyarliattbregfined) <br />Norm of cwtact person <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 />■ Construct row well Permit no <br />❑ olner <br />Golder Associates, Inc. <br />MWiQawroes <br />44 Union Blvd., Suite 300 <br />3. Refer To (d applicable) <br />►brp hale arb,ordedpnnra <br />War rams ors <br />C17 <br />ebb <br />zip Code <br />tart- 051127 <br />MW -7 <br />Lakewood <br />CO <br />-1 <br />80228 <br />4. Location Of Prnogpmosed Well (important! See Instructions <br />To"id 11e�` <br />303- 980 -0540 <br />� n�, <br />Larimer <br />SE imaethe NW 114 <br />9. PropMd Well Driller License o tional : <br />Socwn <br />Tmmahp <br />Nors <br />Rarge <br />Eorw <br />P,- mamirwor <br />10. Name of Well Owner or Authorized Agent <br />17 <br />8 <br />x <br />69 <br />x <br />6th <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 (13xa). I have read the statements herein, know the contents <br />thereof and stale that are hue to my know/ <br />Dierance a1A1°�� f10RJ ., 111°" (MCI= bw we 1 PW* mar prop" fires) <br />Ft turn N S Ft nom E W <br />SW or enter hA rams here j( ^ <br />Deb (m NdW") <br />02/25/2013 <br />For apbranrnl woes o* — end drecion fiom old wag to fart ores <br />feet direction <br />KahpwV invit rams P+rd daeadtf�nlandoraffx <br />Christopher Krambis, Jr., P.G Senior Staff HydrogeDbgist <br />w.r brebonaddrrea (h& de cry slab. Zip) L.IChockdWalladdrowisagarmaeftail <br />4629 North Overland Trail, Laport, CO 80535 <br />Office Use Only <br />Opaorlalc GPS w*H bcoWn inlommlim in UTM loeneR <br />You awo check GPS unit for required s mill fgo as lobos: <br />USGS Prep rams <br />Dort map ra <br />surface eiw <br />Foma mat be MIA <br />Zma 42 or'" ZOOe 13 <br />Embng 487640 <br />,' 1 �� <br />Receipt area only <br />Urals mart be Meta <br />Daum aeat be ruDSa <br />wrthing 4501426 <br />Urw mot be eel to tae nodh <br />Was GPs unit ,1 - A - ear aboW ❑ YES <br />Rernrrlber to *a Oxhirn to NADe3 <br />Best <br />opY availab le <br />5. Property Owner Information <br />Nam of properly oanrer <br />Holcim (US), Inc. <br />•, � . , C <br />It3ri3ni {I�tttW ,h5 tU..2 <br />r,itr: ? 't,r >�l�' t ?r, 11 [Al <br />M�ryfbeeee <br />3500 I-fighway 120 <br />, . M 110,111 . <br />CKY <br />sbb <br />zn case <br />Florence <br />CO <br />81226 <br />EW WD BA MD <br />Td"hma K <br />719 - 784 -1402 <br />