DWR_2044475

• Permitno: 283206
• Receipt Number: 3645549
• Document Type - Well Permit: Original File
• Annotated?: No

COLOiz_ADO DIVISION OF WATER RESOURCES Office Use Only Form MS-44 (07!2009)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER, CO 80203 l k RE C, F IV FD
phone — info: (303) 866 -3587 main: (303) 866 -3581
fax: [phone] hitp1h~.waternstate.co.us MAY
RESIDENTIAL Note: Al. eth. form to apply f« livestock watarlim � i
Water Well Permit Application WMER
STATE
Review form instructions prior to completing form.
The form must be completed in black or blue ink or typed.
1. A licant Information 6. Use Of Well check applicable boxes
Nam of swcard See instructions to determine use(s) for which you may qualify
ETHAN WALTERMIRE ® A. Ordinary household use in one single - family dweiting
C/O INGRAM DRILLING INC. _ (no outside use)
Maang address P.O. BOX 342 ❑ B. Ordinary household use in 1 to 3 single-family dwellings:
CHir
I Zip cods Number of dwellings:
ESTES PARR CO 80 ❑ Home garden/lam irrigation, not to exceed one acre:
demone 0 '('*" +e<i area irrigated ❑ sq. IL [] acre
( ) 800-410-4542 ❑ Domestic animal waters
2. Type Of Application (check applicable boxes) n9 - (
lei ConstiW new well ❑ Change source (aquifer) ❑ C. Livestock watering (on famnlranc o trartge p>astu
• Replace existing well ❑ Reapplication (expired permit) 7. Well Data (prop
• Use existing well ❑ Rooftop precip. collection Mammrma puarorg rate An urai amount to be withdrawn
• Change or increase use 0 Other: 15 1/3 9Pm acrefeet
3. Refer To (if applicable) Tai depth A"Iff
wktpamdt# Water Co cam 500 feet Granite Fractures
8. Water Supplier
ixeignated sago Determination M _._ vYev name «rr _ -- - -- is this parcel within boundaries of a water service area? OYES [$NO
If yes, provide name of supplier
4. Location Of Proposed Weil (Importaintl See instructions) 9. Type Of Sewage System
LAR IMER 114 of 1* 114 ® Septic tank / absorption leach fail
Section Township N «S Range E «w I Prindp Matdan ❑ Central system: District name:
❑ ❑ ❑ ❑ 6th ❑ Vault: Location sewage to be hauled to:
Distance of well tram sedlon Itrros (meson Ines are typicall not property massy
Ft tan ❑ N ❑ S Ft tan ❑ E ❑ W ❑ Other (attach copy of engineering design and report)
F- moacemeM wells only — dstance and direction from dd WON m new woo 10. Proposed Well Driller License iona :1425
feet direction 11. Signature Of Applicant(s) Or Authorized Agent
Well location address (made sty. state zip) ❑ (aadr if won address is some as In item t. The making of false statements herein conslulutes perjury in the second
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
244-104 (13)(a). 1 have read the statements herein, knowthe contents
Optional: GPS well location irttomm ®on M UTM ionnat: GPS aaNt ae"s are aflfabaws:
thereof and state that they are true to my knowledge.
Format must be UTM Sign from (Mist ion oripinrr gg►tatse) Data
p z«,e 12 «NZone 13 East(nq: 476009
units amust be Meters
Dat most be NAM Northin 4 4 97 5 0 7 Print name a tine
Unit Rug be set to true nom Stephen E Ingram Agent
w-GM unitd+edced f«.a ove ?- (2 YES Reamer -to ut- 1Wtumto NAW3 Office Use Only
5. Parcel On Which Well Will Be Located uSGSmaprrsnro DwtRr�pno. sft>ar
(YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A. You must check and complete one of the following:
❑ Subdivision: Name ScJ sr.J Receipt area only
Lot Block Filing/Unit $6 8t1 760
❑ County exemption (attach copy of county approval 8 survey): 774' Wu)
Name/#r Lot# f"' OTtA!s
12 Parcel less than 35 acres, not in a subdivWon, attach a deed with metes ef^L 7 ;L Trans Number: 3645549
and bounds description recorded prior to June 1, 1972, and a current
deed 5110/201010:18:29 AM ❑ Minim r (~ a copy of the deed orsunreir). Name/# AQUAMAP,s r Total Trans Amt: ❑ Square 40 acre parcel as described in Item 4 wE -Ep ,.7f1gZ4 CREDIT CARD $100.00
❑ Parcel of 35 or more acres (and, a roams aw b description or aavey) wR fI Tender Amount: $100.00
❑ Other (allad, metes 3 bounds desaipton «survey and supporting documents)
B. s of acres in parcel C. Arc ymthe owror of ifs parcel? tea
20 WYES ❑ No (if no- see insttactons) Topo
D. wa I" be tm only wit on this parcel? MES ❑ NO (if no — Ist cow wells)
MY LAW
E. State Parcel i ono : V ' — . -- Div 1 1ND 3 BA_ MD _