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COLORADO DIVISION OF WATER RESL...r2CES Office Use Only ; Form GWS-45(02/2005)
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 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 6. Use Of Well(check applicable boxes)
Name of applicant Attach a detailed description of uses applied for.
Lance F. Messinger O Industrial O Other(describe):
Mailing address _.... O Municipal
12610 WCR 25 1/2 El Irrigation
City __.-. —pill. -..- State Zip code Di Commercial
Fort Lupton I CO 80621 7.Well Data(proposed)
Telephone#
Maximum pumping rate —... - Annual amount to bewMdrswn( ) W# (303)659-6699 Cell#(303)550-6699 gpm •
2.Type Of Application (check applicable boxes) 15 1/3 acre-feet
Total depth • Aquifer --
$] Construct new well O Use existing well 55 Alluvial
❑Replace existing well O Change or increase use feet I
I
O Change source(aquifer) O Reapplication(expired permit) 8. Land On Which Ground Water Will Be Used
o Other: Legal Description(may be provided as an attachment):
3. Refer To(if applicable)
- - - -
WellpermRd l Water Court cased N/A
I
Designated Basin Determination It i Well name or#___.
4. Location Of Proposed
County I - (If used for crop irrigation,attach a scaled map that shows irrigated area.)WELD NW vaofthe Nw 1/4A. *Acres B. ow,er
Secton Township NorS 1 Range EorW PrincipalMendlan _ ______. _ _ -_. ___— -
31 3 l O 66 ❑I 6th PM C. Let any other wells or water rghtsused on thislarq
_line_ _prop_
Distance of wellirem section tires(section lines are typically not property lines)
900 Fl.frcn 5 "❑s 2500 R from®E❑W 9. Proposed Well Driller License#(optional):
Forreplacement wells only-tlistameard tlirection irem old well bnew well 10.Signature Of Applicant(s)Or Authorized Agent
feet direction -- - ----- —-_._---
The making of false statements herein constitutes perjury in the second
Wes location address Or applicable) degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
TBD per Weld County 24.4-104(13)(a). I have read the statements herein,know the contents
Pu UTM format thereof and state that they are true to my. kn
_
You must check GPS unit for required settings as follows: sign here Must al signature) 5-160.or
Date
Format must be UTM '
Optional: well
•
CI Zone/2 or❑Zone 13 Easting Pmt name 8 k !�� ////!'c s Units tarot be Meters ZINC E / • /1 rC5s —Are /� Gconer
Datum must be NADa3 Northing f�
unit must be set to true north Office Use Only
Was CPS unit necked for above? O YES i Remember to set Datum to NADs3 USGS map name DWR map no. I Surface elev.
5. Parcel On Which Well Will Be Located
_._A. Legal Description.
(may be provided as an attachment)' Receipt area only
See attached letter
Invoice 8 538822
5/18/2805 -- 15:56:59
_-
WE $488.00
B. #or acres inparcel i C. Owner "^i Check Purchase- ff661
• cwce
D. Wia the be to only th well on e pa ricer)'A'AYES ONO Of no—list other weft) TOPO
MYLAR
E. State Parcel lD#(optional):
585 DIV , W17 BA MD
2006-1251
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, CO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
Permit#: SP-0400078 Sec/Twn/Rng: 31-03-66 Status: ISSUED
Owner: MESSINGER LANCE Applied: 03/18/2004
Applicant: BOOS DON Issued: 05/2,5/2Q04
Permit Type: CNEW C=Commercial,R=Residential+NEW,REPair,VauLT Finaled: //I I/O
Parcel#: 1211-31- - -
Location: 12610 CR 25 1/2 FT LUPTON
Legal Desctiptionn: , fir- v`1 et
t C' L1t -Ck(CttIC,.d Lyn , N c�
Description: METAL BLDG- SHOP
Commercial: Y Residential:N Acres: 9.16
#of Persons: 3 Basement Plumbing: N
#of Bedrooms: 0 Bathrooms - Full: 0 3/4: 1 1/2: 0
Water Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit#:
Percolation Rate: 11.5 Limiting Zone: 0 ft 6 in Description: SAND & GRAVEL
-Ground Slope: 0 Dir: Soil Suitable: (Y/N) N
..gineer Design Required: (Y/N) Y In 100 Year Flood Plain: (Y/N) N
Minimum Installation Chambers
Septic Tank: 1000 gallons Absorption Trench: 0 square feet
or Absorption Bed: 488 square feet
Actual Installation
Septic Tank: gallons Absorption Trench: square feet
Absorption Bed: 510 square feet
Design Type: 0.4
NOTICE
The issuance of this permit does not imply compliance with other state,county or local regulatory or building requirements,nor shall it
act to certify that the subject system will operate in compliance with applicable state,county and local regulations adopted persuant to
Article 10,Title 25,CRS as amended,except for the purpose of establishing final approval of installed system for issuance of a local
occupancy permit persuant to CRS 1973 25-10-111 (2).
This permit is non transferable and non refundable. The Weld County Department of Public Health and Environment reserves the
right to impose additional terms and conditions required to meet our regulations on a continuing basis. Final permit approval was
contingent upon the final inspection of the completed system by the eld County Dep ent of Public Health and Environment.
X Vy1�iM 11111 (�
Environmental Health Specialist Date
---n:S_FINAL
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