HomeMy WebLinkAbout20030976.tiff • ' . DI\'�I0,1 OF WATER RESOURCES, DEPARTMENT OF NATURAL RESOURCES
Vol Columbine Bldg., 1845 Sherman Street, Denver Colorado 80203
\ / / A PERMIT TO USE GROUND WATER N
L2YJ A PERMIT TO CONSTRUCT A WELL s :•; '
APPLICATION FOR: /-`7 REPLACEMENT FOR NO/ / `1
� j
� A PERMIT TO INSTAL A PUMP. ,>' o i „.•::, ,� j. o
/ / OTHER %-,\ t.:' c)` , ' I r c>
PRINT OR TYPE ,-: \V LOCATION OF WELL ` .1 ,
11
1 APPLICANT �7I / /A._ Ad A . fl u S COUNTY ryJ / �� ,s9':=
Street Address-/ h.:5- N.7;yT fj \Srni-&j //k' 4, of the /A/pb/ r, sec. y�°JAS
Cit & State /r gb �/ ['- /,�p ?
Y /'��t T-�L1�7 %Oh/ �C1 / � T. _, -?4,?,/ , R. �ll //� r � P.M.
Street or
Use of ground water f)6A i/S tic Lot & Block
Owner of land on which well City or
is located Subdiv. Filing
Owner of irrigated
land Ground Water Basin
Number of acres Water Management
to be irrigated District
Legal description of
irrigated land LOCATE WELL ON THE BACK DOFF THIS SHEET
Driller Gho b.K)-rS J),..;1 , Nr) No. tc0.3
I Other water rights on Driller's
this land , Address OH ,60 )(Jr,- P/Ztuj.7i4A) Ca 4e S>66"/
Aquifer (s) ground water is to be obtained
f rom 01 6 P/ e/' acaa2-a,
A;&
Signature of Applicant
•/_orage capacity v/ AF CONDITIONS OF APPROVAL
ANTICIPATED PUMPING RATE 1 /5. GPM This permit is issued contingent
AVERAGE ANNUAL AMOUNT OF GROUND WATER TO upon the signing of House Bill 1160.
BE APPROPRIATED Acre-feet
ESTIMATED WELL DATA
Anticipated start of drilling Apr/43619 7f '
Anticipated start of use 4{A2/ /0 197
1 Hole Diameter: +t V � � O 1� .
4- in. from n ft. to ) t ft. APPLICATION APPROVED:
Sy? in. from ,1 0 ft. to 3b 0 ft. VALID FOR ONE (1) YEAR AFTER DATE ISSUED
UNLESS EXTENDED FOR GOOD CAUSE SHOWN 1.0
Casing: THE ISSUING AGENCY
Plain 4 in, from o ft. to J)5ft. PERMIT NO. 455 UCONDITIONAL L_/
/ in. from ft. to ft.
3s. QAT�tss ED MAY 13 1971
/'serf. 7/ in, from ,D7S ft. to, ft. r/ d )
in. from ft. to ft. f
STA N INE �b""
ESTIMATED PUMP DATA . or ' e1..
// Outlet l BY
Type 564-ON HP Size /L-
APPLICATION MUST BE COM LETED SATISFACTOFOLY BEFORE ACCEPTANCE 2003-0976 (OVER)
WR 2s-70 STATE OF COLORADO
Inds /
Index No. -91 . DIVISION OF WATER RESOURCES
77
f I OFFICE OF THE STATE ENGINEER • r
rNi MAP AND STATEMENT FOR WATER WELL FILING '\
(,necked By :,:t` V
- PERMIT NUMBER 6 7 a - F ECE1V C)
WATER RESCcaC_i •.
STATE OF COLORADO } SS WELL LOCATI - c.-ATE E'�G^`=='
CLAIMANT (s) W 1 W 1 AI1A1 A fl a v i :County
TV
Tti W % of
being duly sworn upon oath deposes and says that he (they) is (are)
Y. '., sec. S
the owner is) of the well described hereon; the total number of acres T �,A1 R t C K./ P.M.
of land irrigated from this well is •
INDICATE WELL LOCATION ON DIAGRAM
work was commenced on this well by actual construction on the
NORTH
day of 19_..__; the sustained
$ I I
yield from said well is gpm, for which claim is hereby ,Made i
I----'- --- +—
for ;� C/N�'S4yC purpose (s);
I
--r----
I m
the average annual amount to be diverted is w _ I >
acre-feet; this map and statement is filed in compliance with law; 3 I I -a rn
he (they) has (have) read the statements made hereon; knows the ! I
content thereof; and that the same are true of his (theirs own
knowiedge. I I
I
.ature I s) 7-4 ' _4 ,•C .L4•C'`.r,.✓1-<2... s ..v1.�.y - I I I [
U#k SOUTH
Address:_ G S & t
jr: 1 WELL SHALL BE LOCATED WITH REFERENCE TO
f' i;i7 f a)4.1 C '� GOVERNMENT SURVEY CORNERS OR MONUMENTS,
/r- l' OR SECTION LINES BY DISTANCE AND BEARING.
Subscribed and sworn to before me on this — day
of ' (... 19.x_.._.__ — • _ft. from sr.::on line.
(North or South)
77
My Commission expires: _: �_a
(Seal) i ft. from season line.
----•- •— LL ._:mss! '.= /;�/ (East or West)
Notary Public
• Grouwid Water Basin
Water Management
WELL DATA
Dist"ict
Date Completed !�-�- •'Y �Y?/ Domestic wells may be located by the following:
Static Water Level . -- LOT , BLOCK
Total Depth of Well --3/ CSUBDIVISEON
FILING 1;
ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF COLORADO ON THIS DAY
OF , 19 .
STATE ENGINEER
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 with the State Engineer within 30 days after the well is completed or within 7 days
-- r I
4
Fn.0 To Type & Color of bf }rial Water p11
Loc. Type Dm,'rig U d $A)- y
0 1 d .5 AA/41 HOLE DIAMETER;
)o 1S �/ �•1iw ° W %//ay
1 �"'5�v p e/[ it-- in. from A ft. to Z b ft.
2Y 5a .510"e r3- in. from ae ft. to 3., b ft.
C G,u L in. from ft. to ft.
se Sa
CASING RECORD
fr
5 .. trb SSA Plain Casing
c f 7 2 ,pack
511 ,443E
Size, kind 'from 0 ft. to +1-f ft,
t, o iss
5"4
Size_, kind from ft. to ft.
145 / 57
1`'r rJL :n
41"11 Size_, kind from ft. to ft.
_ 4 yu / SAA/cl Perforated Casing.
1 z G c /t µ • kH t- Size_, kind L from ft. .to kft,
1w S35 5"-` L Size*, kind'� t� � �bf rom s5 f• ft. to 3;7 a ft.
1 YS �� aK Size......., kind from ft. to ft.
15•32 345 SAN CI X GROUTING RECORD
3 L5 j J _. yi A 1,r: Material .111,-1 (')/Lft/t1 t
. Intervals _
Placement Method Pe v )' & ci
GRAVEL PACK RECORD
Size Interval
TEST DATA
Dee Testedf Li ./ t ` ' —
Type of Pump -, l; b-
. Length of Test / /c 1- '
Sustained Yield(Metered) /' ?A lJ
Drawduwn / 4 S
WELL DRILLERS STATEMENT
The undersigned, being duly sworn, deposes and
says: he is the driller of the well hereon
described; he has read the statement made hereon;
knows the content thereof, and the same is true
of his own knowledge.
Use additional paper if necessary to complete log. /;_
v /
(The of Colorado, County of ) ss License No./. 9
fr
Subscribed and sworn to before me this day of , 19
My Commission expires , 19 .
• Notary Public
/ ; •v:.._
n�..JLORADO DIVISION OF WATER RES: RCW —/
THIS FORM MUST BE SUBMITTED 300 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
/
r `K' PERMIT NUMBER -y4-'-h _7 (:::
WELL OWNER V✓ii- :/4 /'? '4. . ,.`r '' �✓ ''G of the ti/ %<ofSec. , -
iti-
ADDRESS ; K 'I .) 1, !t : -' c ' L ='L 1=" ' T. 3 h' R f kr-- �. P.M.
DATE COMPLETED/+•// A (.' % - — I i 7 lI , 19— HOLE DIAMETER
WELL LOG / in. from 0 to__-__2-s2____ft.
From To Type and Color of Material Water
L 5 7 in. from -20 to --) ft.
Loc.
/ , S ,:s7- y .;J in. from to ft.
DRILLING METHOD ,?. 7A- te, y
% .� l%z_^''` ` w- e/-h' I' CASING RECORD: Plain Casing
x v (1...R Size f' & kind -` t from to 4::);.' ft.
•
sc., .) ,,--: A C
Size & kind from _to ft.
co ii a 0 A'1--
S � a r S h Ar 4- Size & kind from to ft.
.r.1 -7 C!. Perforated Casing
—7 J-/ ' 'lc)
` .� S L Size & kind '£ L from toft.
S ,,77 25 A- N d
Size & kind from to ft.
r .c7,4 ,1/2- L.C.-
J/ '/7
Size & kind from to ft.
.a3 4,' 91/2 3 .4- ti- A J ,,(
,a b„ cc c ,,s..L.,4-..f 4 *L L GROUTING RECORD
7
F/ A- E Material _ 2 C A-I t /vT
S _. ;iy ,E' 0 a /C Intervals
S A. ,✓ n `e s r+. Lk.
Placement Method P° ,'- ,a C b
>S f /° _AI r}- <C
GRAVEL PACK: Size
Interval
TEST DATA
Date Tested Cr,A 7 i ,..: , 19 —
Static Water Level Prior to Test ' r ff. /1 -5 ft.
Type of Test Pump )-7
Length of Test 2- 1~ %' 3
Sustained Yield (Metered) `�. '7 t''
TOTAL DEPTH 2 /✓ "
Use additional pages necessary to complete log. Final Pumping Water Level /.2, F l
i
'.PUMP INSTALL. .i ION REFPT ;+ a •
•
71.e.Pump Make Lj =/,r ;i S —k— .,?. �: \
Powered by d L I= " 7 i1 t <<_ HP ' ` • .
Pump Serial No. W
a
W WATER
Motor Serial No. la 3 w
0> TABLE
F W
Date Installed —1t. 4. t. ; — 7 1 Fa
in
Pump Intake Depth _1 j—...).- t T w
s
Remarks _ �.
z ,
w
g ae1/4 =` DTI
a
WELL TEST DATA WITH PERMANENT PUMP a. I`. o•
o F ::
Date Tested Cr L` L Y /L - -2 J z '• CONE OF
Static Water Level Prior to Test ./ H c • " DEPRESSION
.
Length of Test Hours
S,...ained yield (Metered) / r GPM
Pumping Water Level /2 .S I / • `:
•Remarks `�
• N
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 is true of his own knowledge.
l
SignaturP.2.:4-4--z-es--1 !�-Ce License No. •Tc
State of Colorado, County of SS
Subscribed and sworn to before me this— day of , 19 _,
r My Commission expires: , tg _
, Notary Public
FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE'FORM c,ust be an original copy on both sides and signed.
WHITE AND GREEN copies must be filed with the 5taie Engineer.PINK COPY is for the Owner and YELLOW COPY is for the Driller.
i
("1 n
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, COLORADO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
STATEMENT OF EXISTING SEPTIC PERMIT
Permit #: SE-0200055 Sec/Twn/Rng: 25 03 65 PERMIT
Owner: CONNER ANGELA Applied: 06/17/2002
Applicant: FINNICK JAMIE
Parcel #: 1213-25-0-00-009
Location: 23094 CR 30 HUDSON 25 03 65
Legal Desc: 11472 PT NV/4 25 3 65 BEG SW COR SEC NODS
4'E 3018.07' TO TRUE
Description: MODULAR
Commercial: N Residential: Y Acres: 53
# of Persons: 4 Basement Plumbing: N
# of Bedrooms: 3 Bathrooms - (Full): 2 (3/4): 0 (1/2): 0
"ater Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit Number:
Septic Tank: 1000 Tank Material: CEMENT
Absorption Trench: UNK sq. ft.
Absorption Bed: UNK sq. ft. Year Installed: 1972
NOTICFF
The property owner/agent has certified by Notary Seal that the above described septic system is in fact installed as described,and
exists n this time on the parcel identified above by the parcel number and/or legal description,and further states that the system
IS/IS NO'1 w good working order and to the best of his/her knowledge IS/IS NOT failing to function properly.
The property owner/agent further understands that any falsification or misrepresentation may result in the revocation of any permit
granted based upon this information hereby submitted and in legal action for perjury as provided by law,
The Statement of Existing Record relies on information the property owner or his/her representative provides,under oath, indicating
current status of the system and representing to the best of his/her knowledge that the system IS/IS NOT failing to function properly.
Issuance of the Statement of Existing Permit for any system does not constitute assumption that the site was evaluated or inspected
during any phase of construction by this Department to meet regulations.
to
Envir ental Health Specialist Date
Form:S_EXIST
. WELD COUNTY HEALTH DEPAkTMENT
(Th 1516 Hospital Rood
Greeley, Colorado PERMIT NO.__1 ' ___
Ph. 33e-n540
Application for permit to Install, Construct, an Individual Sewage Disposal bystem.
' 9wner �9- �� �! e c.
�_ !✓�/ T/.C_!4 � �/� Address y�� -� -••5:a� Phone c41-34-��
Direction to site: Hwy________ Rd..— _ Nmi„ Emi., SLZmi., W mi. _
__ _ c:-T, .• /• r• �» tic c — s'r..i�r S. .oli o—j./-'1C' - .1 .
�ecOnlr� O `Jo Si (-> n �--R� J C
,4/ L) w- =Legal Description: Pin. Se , T'-3N, Subdiv. Lot._.__._Blk_
General Information Dept. Use Only
No. Bedrooms_ 7--,-/-- No. Persons Perc. Rate (Avg. of 3)_._____> _
No. Baths__l. Basement Plumbing
Soil Type_ 2.. ..-„,in
Size of Lot r$,--.:() l' a c•1 0,..4 —r- H2O Table Depth_ 72g- '
H2O supply lif well give depths— Z../ ./Z-•._ ?‘ Lot Grade f- '6 1-2
New Home Mobile Home Z.•-•"-----Modular_Add'n Requires Engineer Design Yes-No
Type of sewage disposal requested: —_
If yes — reason
Septie--tenk ,J! -Privy Other Comments:__ —
ri /6 t 0 Installation Instructions: (Minimum Requirements)
___25- __L
Septic Tank ? c o •ip••t,r,r.. Gals. Absorption Trenches -24-0 Sq. Ft.
or
Special t Instructions _ Seepage bed -`+L) _Sq. Ft.
This system will be constructed and installed in accordance with the above specifications and regulations re-
garding individual sewage disposal systems in Weld County, Colorado
This permit shall expire at the some fine .c the building permit, on, if no building permit is iss d, the permit
shall expire 120 days after its issuance, if construction bus not been corn aced.
Date:.--- " + 7 • ,/9 d . Owner:2+�/( r m D i
�� af
Applicant:The plans and specifications as shown are approved pending payment of permit fee.
. Dote: _ • //L��`7 L
Sanitarian rtz
The above system ins• ct and /��6 gamply with plan and des riptign.
Systems Contracto . -_� ' a24/24.•• Date:Date:—-- ,.eye-; 074 /970
/ `s-
7 Sanitarian: -1i. ' ....m l�h'�.C .e y
Engineer Review: _— e.1
_—
• (Dat& ISignoture)
Permit Fee: $ , i2-4-1-7 d-}—,
/ /f
eceived by: ,/� sl- t2 4 . _ Date: .i----2 -'-f2-1•7
----,;;;;;--
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