HomeMy WebLinkAbout20093209.tiff COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(06/2006)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST,RM 818,DENVER,CO 80203
phone—info:(303)866-3587 main:(303)866-3581 fax:(303)866-3589 RECEIVED
http://www.water.state.co.us
i• GENERAL PURPOSE AUG 18 2009
Water Well Permit Application
Review Instructions on reverse side prior to completing form. WATER RE'S(ID� 5
The form must be completed in black or blue ink or typed. sTAT S
1.Applicant Information u_— 6. Use Of Well (check applicable boxes)
Name of applicant Attach a detailed description of uses applied for.
2----'c n Lc" ( 0 Industrial IN Other(describe):
Mailing address _ -'—" 0 Municipal
// 7O /u c St. ❑Irrigation
City State - Zip oode --- ❑Commercial
t. Lt,/, ‘2,1 (12 �'t9GZ l — 7.Well Data (proposed)
Telephone*% E-rnail(Optional)
( ) 35-6-�30�r3 -74i•, e L�,, Maximum pumping rate gpm Annual amount to be withdrawn
u nsG k•r s TJ�1
2.Type Of Application (check applicable boxes) 5V _ 20 acre-feet
total depth ----1—Aquifer ------'-�
®Construct new well 0 Use existing well -7 3 �f
0 Replace existing well 0 Change or increase use /� feet Laver -74 4oe
❑Change source(aquifer) 0 Reapplication(expired permit) 8. Land On Which Ground Water Will Be Used
❑Other: Legal Description(may be provided as an attachment):
3. Refer To(if applicable) Sc?,,,,, cr 3 S.4
Well permits Water Court cased �—
Designated Basin Determination it Welt name or#
4. Location Of Pro osed Well (If used for crop irrigation.attach a scaled map that shows irrigated
—--- -
County / / ------ .—._._._........... ...._ area.)
e I c /t/f W v4 or the _S E V4 A. #Acres - _... B. Owner
--- - -
Section Township N or S Range E or W Principal Meridian
• 33 I .23 0
- — / C. List any other wells or water rights used on this land
Distance of well from section lines(section lines are typically not property lines)
2600 Ft.from ONUS /gz5- Ft.from N E❑W 9. Proposed Well Driller License#(optional):
For replacement wells only-distance and direction from old well to new wet 10. Signature Of Applicant(s)Or Authorized Agent
feet -_ direction "The making of false statements herein constitutes perjury
p 4 ry in the second
Wel location address(Include City,State,Zip) 0 Check if well address is same as In Item I. 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 original signature) Date
Optional: GPS well location information in UTM format You must check GPS unit for
re
quired settings as follows: —
`
O c9= .
Formal must be UTM Pnnt name 8 title -
C1 Zone 12 or O Zone 13 Easting �� C'
Units must be Meters �'� r:..5J11r .'�rJ
Datum must es NADS3 Office Use Only
Northing ---m — — -- --- — — — — —_----
Unit must be set to true north USGS ap name DWR map no. l Surface elev.
Was GPS unit checked for above? ❑YES Remember to set Datum to NAD81
5. Parcel On Which Well Will Be Located Receipt area only
SPLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) -
A. Legal Description(may be provided as as an attachment):
See. y�!G �f
Trans Number;3642228
8/181200910:28:49 AM
Geoff Davis(21)
Total Trans Amt:$200.00
CREDIT CARD
8. #of ease in parcel C. Owner ---. _..________-- — -- QR4er A[!l0LtE)t` MC 00_ --�_--
WE
WE
D. Will this be the only well on this parcel?OYES ONO(if no—list other wells) CWCB
.
T0PO 2009-3209
E. State Parcel ID#(optional): MYLAR
585 DIV WD BA MD
1,000L- 1k:—NA rn_r r,2avxs k -b Ira vi-
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