DWR_4296635

• Permitno: 335400
• Receipt Number: 10037133
• Document Type - Well Permit: Original File
• Annotated?: No

Form No. STATE OF COLORADO Office Use Only
GWS-44 OFFICE OF THE STATE ENGINEER RECEIVED
2/2024 1313 Sherman St., Room 821, Denver, CO 80203 07/15/2024
Page Phone: [phone] Webste:htps://dwr.colorado.gov WATER RESOURCES
1 of 3 Email to:dwrpermitsonline(cDstate.co.us
STATE ENGINEER
RESIDENTIAL Water Well Permit Application COLO
Note:Also use this form to apply for livestock watering
Review form instructions prior to completing form.
1. Applicant Information 6. Use Of Well check applicable boxes)
Name ofApplicat(s) See instructions to determine use(s)for which you may qualify
A�A,,N D RA 8 (A T LE r1 ❑A. Ordinary household use in one single-family dwelling
Maigng address (no outside use)
O oX 130 4
City State Zi Code
®B. Ordinary household use in 1 to 3 single-family dwellings:
C ,41 1 I 1 6 2 6 Number of dwellings: /
Telephone#(area code&number) I E all(online filing rgquired)
303. $$4"• Sg 8 3 IqTeKa 8 y ICIZ Y 6 ra 44h. M 0 Home gardeMawn irrigation, not to exceed one acre:
2. Type Of Application(check applicable boxes) area irrigated 1 ❑sq. ft.0 acre
29 Construct new well ❑Change source(aquifer)
❑Replace existing well ❑Reapplication(expired permit) ❑Domestic animal and poultry watering(non-commercial)
❑Use existing well ❑Rooftop precipitation collection
[]Change or increase use ❑Other: ❑C. Livestock watering(on farm/ranch/range/pasture)
3. Refer To(if applicable) 7.Well Data(proposed)
Well permit# Water Court case# Maximum pumping rate Annual amount to be withdrawn
GPM acre-feet
Designated Basin Determination# Well name or C Total Depth Aquifer
4. Location Of Proposed Well SEE INSTRUCTIONS 8.Water Supplier
Property address(include City,state,zip) U Check if well address is some as Item 1 Is this parcel within boundaries of a water service area?BYES A NO
ZIls' Cip- Rd. 3 . C RA l , CO 8 1 6A If esprovide name of supplier:
Rule 6.2.3 ❑Yes ❑ No County 9. Type Of Sewage System
(see instruction for information) r'/ 01 r 47' N Septic tank/absorption leach field
Sedion Tow,n�jip N or S Range E or W Principal Merid'an
a D 0❑ � ❑� 6)rX -PM ❑Central system: District name
Preferred location format: GPS well location information in UTM format. The ❑Vault:Location sewage to be hauled to:
following GPS settings are required: Format must be UTM. Units must be in
meters. Datum must be NAD63. Unit must be set to true north. ❑Other(explain)
[3 Zone 12 or®zone 13. 10. Parcel ID# (optional):
Easting: O2� + 4 9 c4 11. Proposed Well Driller License#(optional):
L7(1 q 9 6 7_3 12.Sign or Enter Name of Applicant(s)or Authorized Agent
Northing: 1 7 The making of false statements herein constitutes perjury in the second
Optional Location Information(must be provided if Rule 6.2.3 is not degree,which is punishable as a class 1 misdemeanor pursuant to
selected and a GPS location is not provided above): C.R.S.24-4-104(13)(a).I have read the statements herein,know the
� 6' r�� contents thereof and state that the are true to my edge.
0114 of the l`l C 1/4 Sign or enter nome(s)of person(s)submitting application Date(m+Jddryyyy)
feet from the❑N.or®S.Line,
feet from the❑E.or®W. Line
5. Parcel On Which Well Will Be Located Ifsgning print name
(You must attach a current deed for the ll ing roL4 A LEA/ A . 1 A W T LC
A. You must check and complete are of the following: !�f-k (�J
❑ Subdivision:Name Title
Lot Block Filing/Unit }�
[3 County exemption(attach copy of county approval&survey) Q IV f"v�
Name/# Lot#
❑Parcel less than 35 acres,not in a subdivision attach a deed with metes Office Use Only
&hounds description recorded prior to June 1,1972,and current deed
❑Miring 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. #Manes in parcel C.Are you the owner of this parcel?If no,list owner. 0037 33
0 aYES ❑NO
D. W K this be the only well on this parcel?❑YES * NO(if no—list dherwells)