HomeMy WebLinkAbout810535.tiff 11i •
C,QLO, DO DIVISION OF WATER RESOURCES
PRINT DIN BL INK 818 Centennial Bldg., 1313 Sherman St. 14„TiF Ehu
COPY OF AC Denver, Colorado 80203 COIO
STATEMENT AILED aREEtEist CLO1-1^
ON REQUEST. STATE OF COLORADO / AFFIDAVIT
SS
COUNTY OF Weld
x STATEMENT OF BENEFICIAL USE OF GROUND WATER
AMENDMENT OF EXISTING RECORD
X LATE REGISTRATION
PERMIT NUMBER 11818 '1 LOCATION OF WELL
rHE AFFIANT(S) ''Cld County County O d}rtf
whose mailing
address is o zc
. nX , :Q—__ __ •PI % ol the .jr- Y. Section
1?
_
City -' rY r_e-'lt s -£01 OY�LISh �''lf:J7nia rn w� T a 5 _ in o'u(si ' Rng itP IC« vn 6 M
being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon, the well is
located as described above, at distances of 12r1n, feet from the _ t'. section line and npgrl feet from the
East section line; water from this well was first applied to a beneficial use for the purpose(s) described herein on the
ever ?5
day of ,' rs a
.__ me maximum sustained pumping rate of the well is 1c gallons per minute, the pumping
rate claimed hereby is - 1r, - gallons per minute; the total depth of the well is r-,7 feet; the average annual amount
of water to be diverted is _ 1 acre-feet; for which claim is hereby made for 'tnusnhnlr', Iiv?Stock F,
yard wateri rin purpose(s); the legal description of the land on which the water from this well is used is
NW 1, NE ?i. Soc. 17, Twp 5 `i, npr , ` r,Y. of which
1 acres are irrigated and which is illustrated on the map on the reverse side of this form; that this well was completed in
compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he
(they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge.
( LETE REVERSE SIDE OF THIS FORM)
Signature(s)
,gyp FOR OFFICE USE ONLY
Subscribed an sworn-� " t-E'
to before me on this °�, day of . 19 i/
(/4 Court Case No
My Commission expires: ( d/,�. /y a
Friar _ Mo. Day Yr
o-7Yt—
Div. Cty.
ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO
PURSUANT TO THE FOLLOWING CONDITIONS: Sec. --- -
Well Use
Dist. _ Basin Man. Ohs
31Jta35
FEB 0 91981O-16V - --- D..9u-r�,,.a
DATE Assistant STATE ciNEeR BY i
Well drilled by Unknown Lic. No.
Permanent
Pump installed by Unknown Lic. No.
Meter Serial No. ❑ Flow Meter Date Installed Over 25 years ano
Owner of land on which
water is being used Veld County -
THE LOCATION OF THE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS THE
AREA ON WHICH THE WATER IS USED MUST BE SHADED OR CROSS-HATCHED ON THE DIAGRAM BELOW.
This diagram represents nine (9) sections. Use the CENTER SQUARE
(one section) to indicate the location of the well, if possible.
I I I 1 I I
- + - +- J- --- + f - F -
I I I I I .+--.._.
+. + + - + + - +- —
�— NORTH SECTION LIME I I
NORTH
/I' — + — I- �-, - x —. w + __ } -
I v+ Jvo
m z
o •_
I I
o U Z
2
w
r- v)
-- + --- + rn, a + -- + — 1"'
w
I I SZ'YV-7(1 ,4) 1-r,? I I +
SOUTH SECTION LINE
+ + — + -- + + — f —
I I I I I I -1
THE SCALE OF THE DIAGRAM IS TWO INCHES E UALS ONE-MIL E
+ + H- + + + i
�-1I Milei
WATER EQUIVALENTS TABLE (Rounded Figures)
An acre-foot covers 1 acre of land 1 foot deep.
1 cubic foot per second (cfs) . . . 449 gallons per minute (gpm).
1 acre-foot . . . 43,560 cubic feet . . . 325,900 gallons.
1,000 gpm pumped continuously for one day produces 4.42 acre-feet.
100 gpm pumped continuously for one year produces 160 acre-feet.
(WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER
PINK COPY WILL BE RETURNED TO OWNER)
Wv l ,.l?i, „, COLORADO DIVISION OF WATER RESO . .C4
818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 81203 �y �
PERMIT APPLICATION FORM REULIIv7ED
Application must • 7
be complete where I 1 A PERMIT TO USE GROUND WATER JAN 2 9981
applicable. Type or (X ) A PERMIT TO CONSTRUCT A WELL _ l7ER s-
print in BLACK FOR: I X ) A PERMIT TO INSTALL A PUMP RESocnCrw
INK.No overstrikes StiTE ")IPo[ER
or erasures unless (X 1 REPLACEMENT FOR NO riot Reni stererl coif,
initialed. I ) OTHER _
WATER COURT CASE NO.
(1) APPLICANT - mailing address FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN
// 6 NAME Weld County Receipt No. 272 /
STREET Box 758 Basin _ Dist.
CITY Greeley, Colorado 80532 CONDITIONS OF APPROVAL
(State) (Zip)
TELEPHONE NO. 53_1000 '7!'n This well shall be used in such a way as to cause
no material injury to existing water rights. The
(2) LOCATION OF PROPOSED WELL issuance of the permit does not assure the applicant
that no injury will occur to another vested water
right or preclude another owner of a vested water
County elrl right from seeking relief in a civil court action.
Nt.! Y. of the NE /, Section 12 1 1818'7
FPROVEO AS A REPLACE :'; OF \'JELL NO __ .
Twp. 5 r-i Rng. 55 I l 5 P.M. 1-7 F�,�ti F(NG WELL Wlll , 1 '_ :.. ICCLU 1,111D abi\I IDONE'D
iN.s! !, .wl ll � 1 ,�1:1 t , .ri-JL I) 1 jt F.:•; %NOCCO L It, t 0 'THE ('v
(3) WATER USE AND WELL DATA EGULJ ;0NC FORWAI ' u:;J I ' I ,I ( ) J I
.
ON F2 .C OR3. THE LNG( ,..L) AFf ' AVH f+US G,
Proposed maximum pumping rate (gpm) 15 I.11.1,,it i'-.D 'V I1HIN1 six-r? (c./.-(c./.-).;� DAYS AFTER 1He
NE
'.! 11:uC. taat } (`q 'JJ V L, A FlRi,41idG THA"(l
Average annual amount of ground water O
1 ELL LVO. 1 � ' I WAS PLUGGEDEL AND ABANDONED.
to be appropriated (acre-feet):
Number of acres to be irrigated: 1 TIT gunCTPAL OR COUN'PY GOVEPNMENT
Proposed total depth (feet): ?N' t':r.':•L Li; CG?f^':L Y .i. I•'uU.'..TT.'IG
Aquifer ground water is to be obtained from: CO2aE'i.Ir.i) v,,.1_..i,Tu ,- 1 ilr4.
gravel
Owner's well designation
GROUND WATER TO BE USED FOR: PAIN! ?'M7
,. ? . e Pi g
( ) HOUSEHOLD USE ONLY - no irrigation (0) --i
( X) DOMESTIC (1) 1 I INDUSTRIAL (51
( 1 LIVESTOCK (2) I 1 IRRIGATION (6)
( I COMMERCIAL (4) ( I MUNICIPAL (8)
I 1 OTHER (9) APPLICATION APPROVED
DETAIL THE USE ON BACK IN (11) af318 7 A
PERMIT NUMBER
(4) DRILLER Lesh Drill inn For DATE ISSUED _-01?p9 1t 83
Name Cummins Pell Works EXPIRF�LON DATEcp ,.
Street 121 - 12,thStreet `6 e Al Cie
Ci
ty z0 :
TA Eit No. 473 - Lesh
LD. / - C'4&
__ COUNTY ‘ Z
(5) THE= LOCATION _OF THE PROPOSED •WELL and thcatta on (6) THE WELL MUST BE LOCATED BELOW
which the water will beused must he indicated on the diagram below. by distance, limn section lines.
Use the CENTER SECTION (1 section, 640 acres) for the well location.
—I- --- -- -.f --- - I- - -- 1 -- ---i 12t1� It. Irunt north sec. line
+ -1-^ -�-- -.- - �. (north Or south,
I< -----i MILE, '280 FEET•______ 21'r) it. how East sec.line
(east or west)
f -I- + -1- + --}-- + -i_
LOT BLOCK FILING u
I
I SUBDIVISION
1- -1- _ NORTH SECTION LINE T +
T 1 — -t
1 I I (7) TRACT ON WHICH WELL WILL BE
LOCATED Weld County
NORTH : X Owner:
Iw_ ..- .. -- —m
T z D + No. of acres 1 Ff7 Will this be
J cn
p I m the only well on this tract? NO
w S (8) PROPOSED CASING PROGRAM
N
'
y ` t— i Plain Casing
t++ I _ _ z
+'- 3 - -1- --r 4- ^+ + -' 5 in. from 0 ft. to 30 _ft.
1 I I
in. from ft. to . ft.
4- — 4- - - e eS ,0 _. _4_ _ 4 Perforated casing
SOUTH SECTION LINE
I I 5 in, front 3n ft. to 5'•� ft.
+ I- 4- -,- 4- 4 + -4- in. from_ _ft. to `t.
(9) FOR REPLACEMENT WELLS givedistance
and direction from old well and plans for plugging
it:
1gfl' Pest
The scale of the diagram is 2 inches= 1 mile
Each small square represents 40 acres.
1,1/ATER EQUIVALENTS TABLE (Rounded Figures) As f1P.1' State regulations
An, acre-foot cower', 1 acre of land 1 foot deep
1 cubic foot per second Ms) . . .449 gallons per minute(gpm)
A family of 5 will require approximately 1 acre-foot of water per year.
1 acre-foot . . . 43.',60 cubic feet 325.900 gallons. _. -..
1,000,gpm pumlro,J continuously for one day produces 4.42 acre•feet.
(10) LAND ON WHICH GROUND WATER WILL BE USED:
Owner(s): ('lel d Cnllnty No. of .rr rr,: 16n
1
Legal description:_1!V•1 N S�t_ 12, is,o ' LI _g c w_2_-_C.,-_(-M. -
(11) QETAI LED DESCRIPTION of the use of ground water: Household use and domestic wells must indicate type of disposal
system to he used.
Pause, livestock. yard watering
Septic tank and leach field
(12) OTHER WATER RIGHTS used on this land, including wells. Give Registration and Politer Court Case Numbers.
Type or right Used for (purpose) Description of land on which used
1J-546` 011961 n Irrigation 16`) Acres N L; of Section 12
(13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS
TRUE TO TH -.BEST OF H KNOWLEDGE.
E /12.--4.--Z----..._
SIGNATURE F APPLICANTfS)
Use additional sheets of paper i' •.n;+'-.. .'. ••equired.
W RJ-26-72
C JRADO DIVISION Cr WATER RESC .CES
THIS FORM MUST BE SUBMITTED 101 Columbine Bldg., 1845 Sherman St.
WITHIN 60 DAYS OF COMPLETION Denver, Colorado 80203
OF THE WORK DESCRIBED HERE-
ON.TYPE OR PRINT IN BLACK WELL COMPLETION AND PUMP INSTALLATION REPORT
INK. PERMIT NUMBER 11"187-A
WELL OWNER Weld. County _ R'•I % of the. _ Nti '''A of Sec. 12
ADDRESS Box 758 - Greeley. Colo. 90631 _ T. N , R. 65 W 6 P.M.
DATE COMPLETED 2-27-'1 , 19 _— HOLE DIAMETER
WELL LOG T2P1 in. from�' to 1+5 ft.
Water
in. from _to ft.
From To Type and Color of Material Loc.
_
0 2 Top 3otl in. from, to_. _ft.
2 11 Med. Loose Gravel
11 21 Blue whale CASING RECORD: Plain Casing
21 45 Ned. & Lrg. Very Loose Gravel
Size 5 & kind a from 020 to _20____ ft.
Size & kind __from to _—___ft.
Size _— & kind ___ from _ to __ __ft.
Perforated Casing
Size _5 & kind clastic from 20 to w __ft.
Size & kind from ___ to ft.
Size & kind _from to _ ft.
GROUTING RECORD
Material Cement
Intervals _ 0 — 11'
placement nnothod loured J
GRAVEL PACK: Size 3/R
Interval __ 11 — 40'
TEST DATA
Date Tested 2-27—r;1 , 19
Static Water Level Prior to Test 11 _. ft.
Type of Test Pump Haler
Length of Test 2 hours
Sustained Yield (Metered) 15 -
TOTAL DEPTH 40 12'
Use additional pages necessary to complete log. Final Pumping Water Level _
PUMP INSTALLATION REPO! J :_`
'ump Make Unknown �t, �n ,,1.•"3.
:,. : ui \`
TYPe
A y
:' A
'owered by HP -___-- f• 'a
'ump Serial No. `' '"
'i ',r 3 J WATER
Motor Serial No. .___ . _ .. ___ w �w TABLE
w f'"w
)ate Installed __. 1-
c 1-
cc
'ump intake Depth - -
Cummins Well ii orks will install �'
3emarks ----- —--- _ z 0 .-
cur-, .;_
tal\ N. , .:, /
/
Q �� .y, i
2 .
VELL TEST DATA WITH PERMANENT PUMP a • `:r
to 0
a I- R
)ate Tested ._.._-- Unknown — — a
z ', CONE OF
f- a. ; .;r DEPRE.5SI0N
static ,Hater Level Prior to Test _ i- 0
y-
_ength of Test -._ Hours ^y- '
tti: -i:r
sustained yield (Metered) _ _ _._ GPM f: -'e• t
'umping Water Level ___._- __._.__— —.__ 4.•,..,I
•
Cummins jell or1:e will teat pump. t,
:3emarks _ _ _.- _ y
i___
CONTRACTORS STATEMENT
The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or
pump installation described hereon; that he has read the statement made hereon; knows the content
thereof, and that the same *s true of his own knowledge. ) ,/,r‘((.! 7 /.3.eil , 21
----
Signature -��' '. /�r' ' � " = ---_ a" License No. .._ —___
State of Colorado, County of —.—__ —. _._ _ SS
Subscribed and sworn to before me this —._— day of --_._.__-. , 19 ___._.. .
My Commission expires: __. _ , 19 _. ___- .
Notary Public
1 r ORi TO 5E- MADE. OUT i 'N QUADRUPLICATE: WHiit- FORM ,n,...:t be .ri t,riainal copy on bcrh s+Jes and sryned.
VIHITE :r4'i ..Rt_t N •ch!ec.:rat:I ne filed with th ri•-+: E..":+w.c.s PINK C:GPY is for Ill, Owner .ur•1 YELLOW COPY is for the Driller.
W J R-26.77
COLORADO DIVISION OF WATER RESOURCES
THIS FORM MUST BE SUBMITTED 1313 Sherman Street - Room 818
WITHIN 60 DAYS OF COMPLETION Denver, Colorado 80203 Pump THE WORK DESCRIBED HERE- Pump Installation Only
ON.TYPE OR PRINT IN BLACK WELL COMPLETION AND PUMP INSTALLATION REPORT
INK. PERMIT NUMBER 113187-A
WELL OWNER 17eldt County __ __ --- ---- of the _. ME 1% of Sec. .__ 12_-
ADDRESS Box 75R, Grceloy, Colo. P.0631 _ T.__5--_ _____?l , R. 55 t4 ,---=".t� -- P.M.
DATE COMPLETED . , 19 -- HOLE DIAMETER
-------in. from __to__ —_-ft.
WELL LOG
Water
in. from to ft.
From To Type and Color of Material Loc. ---- -- _ ._
_.— in. from _._ to__- —ft.
DRILLING METHOD___—__._ ---
.. CASING RECORD: Plain Casing
Size __ & kind from __to . ft.
Size --_ & kind _._ from _— __ to _ ft.
Size ___- & kind _____ from - — to — ___ ft.
Perforated Casing
Size & kind - _—__ from _. _to _ ft.
Size & kind —_. _from _._—to . __ ft.
Size _ _ & kind _——_ _from __ to —_ __ft.
GROUTING RECORD
Material
Intervals — —
Placement Method
GRAVEL PACK: Size -
-_ --- ----
Interval
TEST DATA
Date Tested - --- • 19 --
Static Water Level Prior to Test ___ _ ft.
Type of Test Pump —---
Length of Test—.
Sustained Yield (Metered)
TOTAL DEPTH Use additional pages necessary to complete log. Final Pumping Water Level _ ---
PUMP INSTALLATION REPORT -:;;r.,'.;
:- -' -A
Pump Make Goulds s
Type submersible ``: � ��
Powered by F.li ntr'4e1ty HP 3/4
Pump Serial No. s#Jy«;Ej4.$ _ !: 1 W
3 J WATER
Motor Serial No. _ Howse ;> w i TABLE
-r. '<. w w
Date Installeo ?-S-RI J aJ
N K
• W
Pump Intake Depth -_. 2i" ` a _ _ _
- - -- - - - - - - - - r -3
Remarks "< 0
Z. z
♦ �/
xd /
f ,
WELL TEST DATA WITH PERMANENT PUMP W - , l:,t
C . 1-
Date Tested zl'
- ,. .. ; ' .zll: 41` • . . 1_ :.. , 11 :S .j. ,i . 1f � ,..-r, . CONE OF
F- a '' zy DEPRESSION
a
Static Water Level Prior to•Testu. =1@rr;'. •. .. , '•: ` "'" F . c Z
Length of Test 0Wi a 7:2••:,-.22, c. '
Sustained yield (Metered) 1 GPNI:� ., «, - ` . yd ;'5O
Pumping Water Level S1 ` r
Remarks _ S
i i2'- . ,t • ,ta . -t 9 .. ..
CONTRACTORS STATEMENT a, '' . -m=°' Ir `?) � I'Iar 4
The undersigned, being duly sworn upon oath, deposes and says.ithat ne is.the cgetractorf fl*e sc;?
pump>iristalldlion—described_he eora; that-he has read tfie statement made hereon; knows the content
thereof, and that the dame is true of his own owled e.
Signature . L� �'c 2 2 License No 57:7er
State of Colorado, County,.of-.�-.— .(i �i3 ( ' - --.,_.. SS
Subscribed and sworn to betoke me-thas 2,,J25- day pf f 1t ii(%, 19 -1/7 51 My Commission expires: 01� � 9 19 /
u " .suers r
•L''''.:2--_2":41.-24-2••• i no �
Notary Public '` i `T1zt�_ sy!
.., ,u., r� rh , s .. _
FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed.
WHITE AND GREEN copies must be filed wihe Stdte E mm 1r_ - neer,PFNKt(t`DP Wiq[fos.ihe.OssaWAndntI2LnL QOPV is for the Driller.
t
OW4-9-76 DIVISION OF WATER RESOURCL.
137,3 SHERMAN STREET, RM. 818
DENVER, COLORADO 80203
WELL ABANDONMENT AFFIDAVIT*
STATE OF COLORADO )
) ss.
COUNTY OF Weld )
I (we) Chuck Carlson, Chairman, Board of County Commissioners
,being
first duly sworn upon oath, despose and say:
That an old well , located in the NW 1/4 of the NE 1/4, Section 12 ,
Township 5 N Range 65 W 6
, P.M. , was replaced
for the following reason(s) :
Old well wall falling in and making water dirty
That the old well , which was replaced by a new well drilled under permit
number 118187-A , was plugged and abandoned according to the
rules and regulations of the State Board of Examiners of Water Well and Pump
Installation Contractors by Cummins Well Works
(person (s) or company)
on February 27 , 1981 .
That the old well was plugged with the following materials placed at the
indicated intervals :
Cement from 0 feet to 11 feet
Gravel Pack � from II feet to 40 feet
Signature of affiant(s) X
Subscribed and sworn to before me this 25th day
of S ptember , 19 81 .
My Commission expires : 023 /7t
Notary Public
*It is the owner's responsibility pursuant to the conditions of approval to see
that the affidavit is returned.
(See reverse side far Abandonnent Regulations)
REVISED AND AMENDED RULES AND REGULATIONS
FOR WATER WELL AND PUMP INSTALLATION CONTRACTORS
ABANDONMENT AND APPEALS SECTIONS
EFFECTIVE DATE -- DECEMBER 15, 1972
Section 1. COLORADO CODE FOR WATER WELL CONSTRUCTION AND PUMP INSTALLATION
(1) These rules and regulations provide minimum standards for location,
construction, modification or abandonment of water wells and installation,
modification or repair of pumping equipment. After the effective date of
adopting of these rules and regulations, no water well shall be constructed,
repaired, or modified or any pump be installed, repaired, or modified contrary
to the provisions of these rules and regulations.
Section 5. ABANDONMENT REGULATIONS
(1) General: The sealing of abandoned wells is intended to prevent con-
tamination of ground water aquifers.
(2) Unconfined Water Wells:
(a) Small diameter wells formerly producing from unconfined material
shall be abandoned by filling with sand or gravel to the static water level,
then with inert materials to within 10 feet of the surface. The top 10 feet
shall be filled with concrete, neat cement, or other approved material.
(b) Large diameter wells formerly producing from unconfined material
shall be abandoned by filling with sand or gravel to the top of the water level,
with.inert material to the surface and by installing a permanent cover of ade-
quate strength water tight at the top of the casing. On farm lands the top 5
feet of casing shall be removed, the hole filled with sand or gravel to the top
of the water level, with inert materials to within 5 feet of the surface, and
shall be capped with concrete or steel 5 feet below the surface.
(3) Confined-Water Wells: Wells formerly completed in confined and uncon-
fined formations or in confined formations only shall be abandoned by plugging
• with concrete, neat cement or other approved material at the first impervious
strata above each zone and cement grouted from the surface to a depth of 10 feet.
No plug shall be less than 5 feet in length.
Section 7. APPEALS
(1) Requests for exception to any of the foregoing rules must be sub-
mitted to the Board in writing and contain all information relevant to the
request. Such requests must specifically set forth why such exception should
be considered.
The Board may make exceptions after due consideration of such appeals.
PART 1 Dealer's
Na N0.3 2619 9
Consumer's Copy m Name me' ��;rnVrr/us CVE« Gl/o Mks
W Dealer's � 7-,6-e-
D Address: /d/. /3 _/ ,5T
Goulds SubSurance® co TownsZip Code I Phone Covers Goulds
Five Year Submersible State: / ��� L„, 60Z-ere/WO I 70/63/ k?5A.,27J9 Pumps Submersible
7EH,
Pump Protection Plan TO: , 10EJ, 13EM
Name ISSUEDof Consumer: /J &25EL(thru 1'4 hp)
In consideration of oaymenl at S15 00 al /�ELD roux/ v
time of pump installation,Dealer agrees to Consumer's J R
_
replace motor andior pump end at no charge Address: Sep, �5O
for the Goulds submersible puma identified on
this certificate if`allure occurs within 5 Town& Zip as
years after date of instarlatien State: i7 7(�ZQ�/>Fann Code: UMI
This protecf_n Dian does NOT cover (y/CES/� - � 0 pQ��.�C�
labor invoived-n pulling o reinstalling
the pump nor failures aft ribrt en o pipe. Pump Model No.: Pump Serial No.: Motor Serial No.: Illr IM
cable,condo or accessories misuse. .°41re CODE U// ��
nor consequent al damages
/36n)0 7y 71055 5 y/055156
The SubSura,cr P o action Plan is an e ended Date of Installation: Dealer's Authorized Signature:
warranty and is net intended to replace ,um'
actual insurance coverage as might be whom
wise applicable or available 7 - 9 7-f/ RAN
Hello