2023-04-19_PERMIT FILE - C1981010 ‎(115)‎

• Permit No: C1981010
• IBM Index Class Name: Permit File
• Doc Date: 4/19/2023
• Doc Name: GX-1 Well Permit
• Section_Exhibit Name: Appendix V
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER CO 80203
Phone: [phone] Fax: [phone] [e-mail]
MONITORING/OBSERVATION
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be typed, completed online or in black or blue ink.
1. Well Owner Information
Name of well owner
Mailing address
City State Zip code
Telephone # E-Mail (If filing online it is required)
2. Type Of Application (check applicable boxes)
Use existing well
Construct new well
Other:
Replacement for existing monitoring well:
Permit no.:
3. Refer To (if applicable)
Monitoring hole acknowledgment
MH-
Well name or #
4. Location Of Proposed Well (Important! See Instructions)
County
1/4 of the 1/4
Section Township N or S Range E or W Principal Meridian
Distance of well from section lines (section lines are typically not property lines)
Ft. from N S Ft. from E W
For replacement wells only distance and direction from old well to new well
feet direction
Well location address (Include City, State, Zip)Check if well address is same as Item 1.
Optional:GPS well location information in UTM format
You must check GPS unit for required settings as follows:
Format must be UTM
Easting
Northing
Remember to set Datum to NAD83
Zone 12 or Zone 13
Units must be Meters
Datum must be NAD83
Unit must be set to true north
Was GPS unit checked for above? YES
5. Property Owner Information
Name of property owner
Mailing address
City State Zip Code
Telephone #
Office Use Only
6. Use Of Well
Use of this well is limited to monitoring water levels
and/or water quality sampling
7. Well Data (proposed)
Total depth
feet
Aquifer
8. Consultant Information (if applicable)
Name of contact person
Company name
Mailing address
City State Zip Code
Telephone #
9. Proposed Well Driller License #(optional):
10.Name of Well Owner or Authorized Agent
The making of false statements herein constitutes perjury in the second
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
Sign or enter full name here Date (mm/dd/yyyy)
If signing print name. Print title if other than land owner.
Office Use Only
USGS map name DWR map no. Surface elev.
Receipt area only
DIV _____ WD _____ BA _____ MD _____
Form GWS-46 (/20 )