HomeMy WebLinkAbout990812.tiff COLORADO DIVISION OF WAI-A RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,RM. 818,DENVER CO 80203
phone - info: (303) 866-35137 main: (303)866-3581
AENERAL PURPOSE Water Well Permit Application
(Please note: other forms are available for specific uses including- residential, livestock, monitoring/observ., gravel pits,registration of old wells)
Review instructions prior to completing form Must be completed in black ink or typed
1. APPLICANT INFORMATION 6. USE OF WELL ( lease attach detailed description)
Name
afapplicant /1 �/.�_ O INDUSTRIAL OTHER: Art�(t. -Ia4Q.
Ilill(^t,I th-?Y73 O COMMERCIAL antttl L,* , , / An
O MUNICIPAL Irrl• je (Ad �`'eloi C`t""hn/
Mailing Address O IRRIGATION {y 5 /
64
❑ FEED LOT--numbe step',
: ` /1 164 nJ
�3 EII�tY� p[ 7. WELL DATA
City State Zip Code Maximum pumping rate Annual amount
I� gpm acre-feet
Attire k- ` ti AOVr ) TOW depth Aquifer __
T hone number(include are code( /
feet
X30 3) 3(, -C/0 8. LAND ON WHICH GROUND WATER WILL BE USED _
2. TYPE OF APPLICATION (check applicable bottles)) A. LEGAL DESCRIPTION(may be provided as an attachment):
01 Construct new well 0 Use existing well Ste_ _iri-dej4 Q, -Av 5q.
❑ Replace existing well 0 Change or Increase Use
❑ Change (source) Aquifer 0 Reapplication (expired permit)
❑ Other: (If used for crop irrigation,attach scaled map that shows irrigated area.)
3. REFER TO (if applicable): B. it acres C. Owner
Water court case 0 Permit 0
D. List any other wells or water rights used on this land:
:margency Verbal 0 Monitoring hole acknowledgment 0
-VE- MH- -
Well name or 0 9. PROPOSED WELL DRILLER (optional)
Name License number
4. LOCATION OF WELL
County Quarter/quarter Quarter 10. SIGNATURE of applicant(s) or authorized agent
die 6llJ ya y. The making of false statements herein constitutes perjury
Section Township N or S Range E or W Principal Meridian in the second degree, which is punishable as a class 1 mis-
3I I ❑ 6 ❑ bi 6 demeanor pursuant to C.R.S. 24-4-104(13)(a). I have read
Distance of well from section lines the statements herein, know the contents thereof, and state
ft from O N O S ft from O E O w that they are true tarry knowledge.
Wel locadan addrae.If dffersm from ppecem eddr®Of epplicablel 'Must pipe(aigroture y/,.
M It,tea,l load , Title / Date
For repleos.nent wells only-distance end amnion from old well to new well j , _- %t
feet direction OPTIONAL INFORMATION
5. TRACT ON WHICH WELL WILL BE LOCATED USGS map name DWR map no. Surface elev.
A. LEGAL DESCRIPTION(may be provided as an attachment):
`�� Office Use Only
5�- !c-�e� DIV
CO
B. STATE PARCEL
ID#(optional): WD
c.*aces intact D. Owns /
I gall- tti4-i 0/12) BA
E. Will this be the only well 6n this tract?
ll'YES O NO (if other wells are on this tract, see detailed inst.) USE(S) _ MD
Form GWS-45 (12/95)
990812
/ � �� � f- /it I� Gic . < S
/ J_)c -ix if/ '1 14.1{ ( C.
Aae,cEFL:: i AC (xi
g2 // /ice-
Cpl � li C %-(< i( 1-tick /
Ace ti K/U it.
( c )
34 /- f / e it
Hello