DWR_3669833

• Permitno: 84716
• Permitsuf: F
• Receipt Number: 10004850
• Document Type - Well Permit: Original File
• Annotated?: No

DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER, CO 80203
RESIDENTIAL Note: Also use this form to apply for livestock watering
Water Well Permit Application
Review form Instructions prior to completing form.
Hand completed forms must be completed in black or blue Ink or typed.
1. Applicant Information
Name(s)
L. Morphew
Mailing address
19057 Puma Path
City
Telephone hWarea code)
■ Construct new well
❑ Replace existing well
❑ Use existing well
❑ Change or increase use
3. Refer To (if applicable)
Well permit #
Designated Basin Determnation #
State Zip code
CO 71201
E-mail
4. Location Of Proposed 111
County
:haffee
section Township N S
6 50 ILl❑
Distance of well from section lines (section lines
ftho.ON ❑S
For replacement webs only —distance and dime
feet
:)plicable boxes)
❑ Change source (aquifer)
❑ Reapplication (expired permit)
❑ Rooftop precip. collection
❑ Other:
case
�en name or a
�1.((117Ef OW A
II ( portanti See Instructior
NW 114oflne NE 1r3
Range Ery W principal Meridian
3 I'1 L NM
Ft. fm.CI E ❑ W
Direction
Optional: GPS well loce8un info tatlon In UTM fmmat. DIPS unit settings are as follows:
For at must be UrM
0 Zone 12 -A Zone 73
Ewing 410119
Units must be Meters
Datum must be NAD83
Northing: 4267242
Unit must be set to we oxm
Remember to ad Datum to NAO83
Was GPS unit checked for above? E YES
(You must attach a current deed for the subject parcel
A. You must check and complete one of the following:
Subdivision: ryName Longhorn Ranch
Lot 6 Block Filing/Unk
❑ County exemption (attach copy of county approval & survey)
Name/# Lot #
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
& bounds description recorded prior to June 1, 1972, and current deed
❑ Mining claim (attach copy of deed or survey) Name/#:
❑ Square 40 acre parcel as described in Item 4
❑ Parcel of 35 or more acres (attach metes & bounds description or survey)
❑ Other: (attach metes & bounds description or survey)
B. # of some innparpd Am you the owner of this parctl?
! YES 0 NO
D. will this be the���//lD#oo /Nply well an this panel?
eS
E. slate parcel (opeorag:
NO (8 no — list other wells)
Office Use Only
Form GWS-44 (0112020)
RCVD DWR
07/23/2020
6. Use Of Well (check applicable boxes)
See instructions to determine use(s) for which you may qualify
❑ A. Ordinary household use in one single-family dwelling
(no outside use)
■ B. Ordinary household use in 1 to 3 single-family dwellings:
Number of dwellings: 1
■ Home gardennawn irrigation, not to exceed one acre:
area irrigated _j qQO K sq. it. 9 acre
❑ Domestic animal watering — (noncommercial)
❑ C. Livestock watering (on farmhanchlrange/pasture)
Maximum pumping rate
Annual amount to be withdrawn
15 gpm
R o. acre-feet
Total depth
Aquifer
100 f`et
ALLUVIAL
Is this parcel within boundaries of a water service area?[J YES NO
E Septic tank / absorption leach field
❑ Central system: District name:
❑ Vault: Location sewage to be hauled to:
❑ Other (explain)
10. Proposed Well Driller License #(optional):
11. Sign or Enter Name of Applicant(s) or Authorized Agent
The making of false statements herein constitutes perjury in the second
degree, which is punishable as a Gass 1 misdemeanor pursuant to C.R.S.
244-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
Sign or ender name(s) of pinsp;fs) submitting applhatmn I Date fmrNddlwm
0'0+ erg YY/0 k,e
Office Use Oni
USGS map name DWR map no.
area only
10004850
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