HomeMy WebLinkAbout20132819.tiffCOLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 818, DENVER, CO 80203
phone — info: (303) 868.3587 main: (303) 866-3581
fax: (303) 866-3589 http://www.water.state.co.us
GENERAL PURPOSE
Water Well Permit Application
Review Instructions on reverse side prior to completing form.
The form must be completed In black or blue Ink or typed.
1. Applicant Information
Name of applicant
Office Use Only
Form GWS-45 (07/2009)
SELECT ENERGY SERVICES
Malang address
24246 CR 34
City
LA SALLE
Taleplar a
(970)284-7820
2. Type Of Application (check applicable boxes)
• Construct new well
❑ Replace existing well
❑ Use existing well
❑ Change or Increase use
3. Refer To (if applicable)
Wel perms
State Zip cods
CO 180645
E-mail (Optional)
6. Use Of Well (check applicable boxes)
Attach a detailed description of uses applied for.
❑ Industrial
❑ Municipal
O Irigation
• Commercial
❑ Dewatering System
❑ Geothermal (O production or 0 reinjection)
❑ Other (describe):
7. Well Data (proposed)
Madnum pumping rate ' Annual amount to be withdrawn
gpm
❑ Change source (aquifer)
❑ Reapplication (expired permit)
C COGCC well
❑ Other:
15
Tots depth
1/3 acre-feet
' Aquder
450 feet I ALL UNNAMED
8. Land On Which Ground Water Will Be Used
Designated Basn Determnat»n
Water Court case N
Well name or
4. Location Of Proposed Well (Important! See Instructions)
County N W
WELD
Section Township N Range EcrW
35 8 E❑ 60 ❑
Distance of well from section lines (mouton lines are typcally not popeny lines)
Ftfron❑N❑S R. from❑E❑W
For replacement wells only— Pawnca and drectin from rid web to new well
feet direction
Will location address (Include City, Slate. Zip) ❑ Check if well address is saute as in Item 1.
1/4 of the
NW 1/4
Pnnapal Mendn
6TH
Optional: GPS well location information in UTM format You must check GPS unit for
required settings as follows:
Formal must be URI
D Zone 12 or ■ Zone 13
Unite trust be Melon
Saturn must be NADa3
Unit must be set to tme north
Wee CPS Welt checed Ice above? O YES
5. Parcel On Which Well Will Be Located
(YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A. Legal Description (may be provided as an atttachment).
has erg 578873
Northing 4497571
Remember to set Datum to NADS3
Legal Description (may be povded as an attachment)
(If used for crop irrigation, attach a scaled map that shows irrigated area)
A. a Acres B. Owner
C. Lis1 sty other wall or wale rights used on this land:
9. Proposed Well Driller License #(optional):
10. Signature Of Applicant(s) 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 here (Must be ortgbtal agralure)
Print name a title
JIM GODDARD, MANAGER
Date
B. N of acres In perch C. Owner
35 BARRACUDA INVESTMENTS
D. WI ha be the only wall on this parcel? EYES ONO (If no —list Other wells)
E. State Parcel IDN (optional)
Office Use Only
USGS map nacre
DWR map no. Surface elev.
Receipt area only
AOUAMAP
WE
WR
CWce
TOPO
MYLAR
5B5 DN_ WD_ BA_ MD
COLORADO
DEPARTMENT
1313
main:
fax:
DIVISION OF WATER RESOURCES
OF NATURAL RESOURCES
SHERMAN ST., STE 821, DENVER, CO 80203
(303) 866-3581 littp.11water.slate.co.us
Form GWS-57 (10/2011)
Application
Applicant's
Receipt No.
Name:
(303) 866-3589 Online Requests:
AskDVVR
COMMERCIAL DRINKING AND SANITARY WELL WORKSHEET
Review instructions on reverse side prior to completing form. The form must be completed In black or blue Ink or typed.
1. Name and Type of Business: SELECT ENERGY SERVICES
2. Is this application for a new well?
Yes
0 No If no, is this application for a change of use for an existing well?
■ Yes Permit Number of well (if applicable)
0 No For wells used for drinking and
sanitary purposes prior to May 8, 1972, a field inspection of the well to
verify historical uses may be required. See form
GWS-12 Registration of Existing Well and
form GWS-12A Statement of Historical Use for
further information.
3. Is the parcel the well is located on (or will be located on) within the boundaries of a water service area (water district,
municipality, water company, etc.) or is water available from another source (such as a well)?
■ Yes If yes, indicate what this other source is
O No
(name of water district/supplier, or well permit number)
4. Proposed type of disposal system to be used:
O Septic tank / absorption leach field
❑ Central System (district name:)
■ Vault (location sewage hauled
to:)
❑ Other (attach copy of engineering
design)
5. Water Demand Calculations (for average factors for water demand see below)
Employees
Number of
X
Number of Gallons
X
Number of Days Employee
=
Gallons per Year
Employees
per Employee per Day
Works per Year
15
X
15
X
365
=
82125
A
Customers
Number of
X
Number of Gallons
X
Number of Days Business
=
Gallons per Year
Customers per Day
per Customer
is Open per Year
10
X
5
X
365
=
18250
B
Other Uses (Note: No uses outside of the building would be permitted for this type of well.)
Type of Use
X
Gallons per Use per Day
X
Days per Year
=
Gallons per Year
X
X
=
C
Total amount
of water required:
=
Gallons per Year
(A + B + C)
=
100375
For wells used for commercial drinking and sanitary purposes
on or after May
8, 1972, the total water demand cannot exceed
108,600 gallons (1/3 of an acre-foot) per year.
For wells used for commercial drinking and sanitary purposes
prior to May
8, 1972, the total water demand cannot exceed 325,900
gallons (1 acre-foot) per year.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices — 15 gallons/person/day
Food Service Establishments (with toilet and kitchen wastes) — 10 gallons/patron/day
Churches (does not include food service) — 5 gallons/seat/day
Overnight Lodging — 50 gallons/customer/day
On -Site Proprietor of Overnight Lodging (i.e. on -site owner of a Bed & Breakfast) — 80 gallons/person/day
Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject.
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
GENERAL PURPOSE WELL PERMIT APPLICATION INSTRUCTIONS
Applications must be typewritten or printed in BLACK or BLUE
INK. ALL ITEMS in the application must be completed.
Incomplete applications may be returned to the applicant for
more Information. Applications are evaluated in chronological
order. Please allow approximately six weeks for processing.
This form may be reproduced by photocopying or computer
generation. Reproductions must retain margins and print quality of
the original form.
FEES: This application must be submitted with a $100 filing
fee. Acceptable forms of payment are check or money order,
payable to the Colorado Division of Water Resources, and Visa,
MasterCard or Discover (card number and expiration date must be
provided on a separate attachment). Fees are nonrefundable.
USES: This form (GWS-45) is to be
commercial, industrial, municipal,
geothermal, recovery wells, and other
noted in the following list:
RESIDENTIAL use wells — Use of form GWS-44 is required
LIVESTOCK watering on a farm, ranch, range or pasture (not
feedlots) — Use form GWS-44
MONITORING/OBSERVATION wells - Use form GWS-46
GRAVEL PITS — Use form GWS-27
REGISTRATION of an existing well — Use form GWS-12 (must
have been in use prior to May 8, 1972)
GEOEXCHANGE SYSTEM LOOP FIELDS — Use form GWS-72
REPLACEMENTS OF WELLS FOR THE ABOVE USES
ITEM INSTRUCTIONS: (numbers correspond with those on the
front of this form)
1. The applicant is the entity for whom the permit is to be issued.
Provide the applicant name and the mailing address where all
correspondence will be sent.
2. Check all boxes that apply.
3. Complete all boxes that apply. If the permit is to be issued
pursuant to a water court decree or a Designated Basin
determination of water right, the case number or determination
number must be indicated. If applying to replace or change the
use of an existing well, the permit number of the existing well
must be indicated.
4. The county, 1/4 of the %section designation (example: NE 1/4 of
the SE'/.), section #, township, range, principal meridian, and
distances from section lines for the proposed well must be
provided. (An option to providing distances from section lines
and the '/. of the 1/4 section designation is to provide an
accurate GPS location (UTM coordinates). If providing a GPS
location, the required GPS unit settings must be as indicated
on this form. Colorado contains two UTM zones (12 & 13).
Zone 13 covers most of Colorado. The boundary between
Zone 12 and Zone 13 is the 108th Meridian (longitude). West
of the 108"' Meridian is UTM Zone 12 and east of the 108th
Meridian is UTM Zone 13. The 108'" Meridian is approximately
57 miles east of the Colorado -Utah state line. On most GPS
units, the UTM zone is given as part of the Easting
measurement, e.g. 1270123456. Check the appropriate box
for the zone.
Exception to above: If you use this form to apply for a permit
to construct a well for commercial exempt/small capacity use
pursuant to CRS 37-92-602 or 37-90-105, you must provide
the following minimum information: (a) the county, section #,
township, range and principal meridian; (b) the subdivision lot,
block & filing/unit designations as applicable if in a subdivision.
You do not need to provide distances from section lines or a
GPS location (UTM coordinates). "Commercial exempt/small
capacity" is NOT the same as "commercial" and is a more
used to apply for
irrigation, feedlot,
uses not otherwise
GWS-45 GENINST (07/2009)
restrictive use category, generally limiting use of the well to
drinking and sanitary purposes only. If you are applying for
commercial use and are uncertain as to whether that use is
"exempt/small capacity", please contact a Division of Water
Resources office (see contact info below) prior to submitting
the application to avoid delays in the evaluation process.
Provide the property address of the well location if one exists.
If it is the same as the mailing address, check the box next to
the well location address.
5. You must attach a current deed for the subject parcel.
Complete all boxes and provide a complete legal description of
the parcel of land on which the well will be located (Box 5E is
optional).
6. Check all boxes that apply and attach a detailed description of
the uses applied for. (Important): For commercial
exempt/small capacity use you MUST attach a completed
worksheet form GWS-57 if the well location is outside a
Designated Basin and form GWS-61 if the location is inside a
Designated Basin.)
7. Complete all boxes.
8. Complete all boxes and provide a legal description of the land
areas on which ground water from the proposed well will be
used. If agricultural irrigation is a proposed use, provide a map
of the land area with proposed irrigated areas accurately
drawn, including section numbers and section lines. A list of all
other wells or water rights used on the described land must be
provided.
9. The well must be constructed by a Colorado licensed well
driller, an authorized individual, or special licensed contractor,
in accordance with the Water Well Construction Rules, 2 CCR
402-2, or under the "private driller" provision as defined in CRS
37-91-102(12). A listing of licensed well drillers/pump installers
is available at htto.Gwww.stateco.us/boe/contractors asp.
10. An ORIGINAL signature must be on the application. The
individual signing the application must be the applicant or an
officer of the corporation/company/agency identified as the
applicant. An authorized agent may sign the application, if a
letter signed by the applicant is submitted with the application
authorizing that agent to sign on the applicant's behalf.
IF YOU HAVE ANY QUESTIONS regarding any item on the
application form, please call the Division of Water Resources Ground
Water Information Desk (303-866-3587), or the nearest Division of
Water Resources Field Office located in Greeley (970-352-8712),
Pueblo (719-542-3368), Alamosa (719-589-6683), Montrose (970-
249-6622), Glenwood Springs (970-945-5665), Steamboat Springs
(970-879-0272), or Durango (970-247-1845), or refer to the CDWR
web site at htta://www.water.state.co.us for general information,
additional forms, and access to state rules or statutes.
COLORADO DIVISION OF WATER RESOURCES GWS-57 (10/2011)
DEPARTMENT OF NATURAL RESOURCES
INSTRUCTIONS FOR COMMERCIAL DRINKING AND SANITARY WELLS
OUTSIDE A DESIGNATED GROUNDWATER BASIN
For all commercial drinking and sanitary wells:
1. The use of the water diverted is limited to inside drinking and sanitary facilities in an individual commercial
business. No uses outside of the building are permitted.
2. The pumping rate shall not exceed 15 gallons per minute.
3. The return flow from the use of the water must be discharged to the same stream system in a location so as to
not injure any vested water right.
In addition:
For commercial wells put to beneficial use for drinking and sanitary purposes on or after May 8,
1972 (See State Engineer Policy dated April 9, 1985 for additional information):
4. The proposed well must be the only source of water for the property. No other water supply source or system
can be available to serve the property. An affidavit or statement by the applicant affirming this situation must
accompany the well permit application. In addition, for property located within the boundaries of a water service
area (water district, municipality, water company, etc.), an affidavit or statement from the supplier affirming that
the property cannot be or will not be supplied water by that entity, must also be submitted with the well permit
application.
5. The well must be the only well on the parcel.
6. The parcel on which the well would be located, must be:
a) Thirty-five (35) acres or more in size. A legal description, in the form of a metes and bounds description
or a surveyor's map of the parcel must accompany the well permit application.
b) If less than 35 acres, the parcel must have been established prior to June 1, 1972 or must be exempt
from the definition of a subdivision pursuant to Section 30-28-101 (10)(c) and (d), C.R.S. A copy of a
deed describing the parcel and dated before June 1, 1972, or a copy of the signed county resolution
exempting the parcel, must accompany the well permit application.
For lots in subdivisions approved on and after June 1, 1972, the recommendations made by this office
in the water supply review process will be honored.
7. The amount of ground water diverted shall not exceed 1/3 acre-foot annually (108,600 gallons). The applicant
must support the well permit application with evidence that the proposed use will not create a demand greater
than 1/3 acre-foot/year.
8. The consumptive use of the water shall not exceed 10% of the volume of ground water diverted. An approved
septic tank and non -evaporative leach field is an acceptable discharge method. Other types of disposal systems
must be evaluated to determine the amount and location of the return flow.
9. A totalizing flow meter must be installed on the well. Permanent annual diversion records must be maintained by
the well owner and submitted to the Division of Water Resources annually or upon request.
10. Submit this form in conjunction with a general purpose application (form GWS-45).
For existing commercial wells put to beneficial use for drinking and sanitary purposes prior to
May 8, 1972 (See State Engineer Policy 90-1, dated January 18, 1990 for additional information):
4. The well must be the only commercial well serving the business.
5. The amount of ground water diverted shall not exceed one (1) acre-foot annually (325,900 gallons). The
applicant must support the well permit application with evidence that the proposed use will not create a demand
greater than one (1) acre-foot/year.
6. A written field inspection report prepared by personnel from the Division of Water Resources may be required to
support the claimed date of first use and type of use. See form GWS-12, Registration of Existing Well, and form
GWS-12A, Statement of Historical Use, for further information.
7. A totalizing flow meter must be installed on the well. Permanent annual diversion records must be maintained by
the well owner and submitted to the Division of Water Resources annually or upon request.
8. Submit this form in conjunction with a registration of existing well (form GWS-12 [may also require GWS-12A]).
CONDITIONS VARY STATEWIDE
MEETING THE ABOVE CONDITIONS DOES NOT GUARANTEE THE ISSUANCE OF A PERMIT
Weld County Environmental Health Services Department
1555 N. 17th Avenue
Greeley, CO 80631
Phone: (970) 304-6415
Fax. (970) 304-6411
Web.. www co.weldhealth.org
Septic Permit Application
Application Number: SP -1300142
App Type: Health \Commercial\New \Septic
JIM GODDARD
SELECT ENERGY SERVICES
3031 1ST AVE
GREELEY. CO 80631
Owner Name:
Parcel #:
Legal Desc:
Site Address:
App Specific Info:
UNITED SURFACE & MINERALS LLC
054135000003-O2555303
LEASEHOLD INT NENW 35 08 60 FEDERAL OSPREY 35-3
TBD CR 105
1/2 Bathrooms
3/4 Bathrooms
Basement Plumbing
Full Bathrooms
Location Description
Number of Bedrooms
Number of Persons
Parcel Acres
Private Water Supply
Public Water Supply
TERMS AND CONDITIONS
A permit fee, as set by separate ordiance of the Board of Weld County Commiss oners stall be required of applicants for new individual
sewage disposal systems lSCS), payable at time of application Permit fees are non-refundable: permit applications are
non -transferable If both a building permit and an ISDS are issued for the same property and construction is not commenced prior to the
expiration date of the building permit, the ISDS permit shall expire at the same time as the building permit .f an ISDS permit is issued for a
property that does not require a building permit, the IS0S permit sha expire one year after is issuance If construction on the septic system
has not commenced Any change in plans or specifications after the permit has been issued invalidates the permit unless approval is
secured from the Health Officer or hisrher designated agent Existed permits can se renewed oy payment of the permit fee only if
A There has been no change in the plans and specifications of the proposed system as set out n the original appl cation or such
change is reviewed and approved by a Division Representative
B The surrounding land, its use or zoning has not changed so -as -to cause the or'gine application not to be acceptable under these
regulations
NOTICE
The completeness of this application is conditional upon further mandatory and addtonal tests and reports as may be required by the Weld
County Department of Public Health and Environment (WCDPHE) The Issuance of the oe•mit is subject to such terms and renditions as
deemed necessary to insure compliance with rules and regulations adopted under article 10 title 25, CRS as amended The applicant certfes
that the proposed system will not be located within 40C feet of a community sewage system The undersigned certifies that all statements
madeinformation and repels submitted herewith are, or will be, represented to be true and correct to the best of hislher knowledge and are
designed to be relied on by the WCDPHE for evaluation for purposes of issuing the permit applied for herein Applicant further understands
that falsification or misrepresentation may result in the denial of the application or revoca!on of any perm t granted, and in legal action or
perjury as provided by law
0
1
No
0
TBD
0
20
80
Well
No
X
Date
Report ID: EHS00056v003 Page 1 of 1
Print Date Time: 6/21/2013 10:16:08AM
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