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2007-2825
COLORADO DIVISION OF WAIRESOURCES Office Use Only • Form GWS-45(06/2006)
DEPARTMENT OF NATURAL SOURCES
1313 SHERMAN ST, RM 818, DENVER, CO 80203
phone—info:(303)866-3587 main:(303)866-3581 fax: (303)866-3589
http://www.waterstate.co.us
AENERAL PURPOSE
ater 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.
Mountain States Line Constructors JATC
c/o Mark Steckel E Industrial O Other(describe):
Mailing address ----- - Municipal
12150 E.112th Avenue E Irrigation
city State Zip code _ - E Commercial
Henderson CO 80640 7.Well Data ro cased
(P P )
Telephone# E-mail(Optional)
(303)227-4811 Maximum pumping rate Annual amount to be withdrawn-_-- --- -
9Pn
2.Type Of Application (check applicable boxes) 100 2.18 acre-feet
— --
Total depth - — Aquifer ----- _---
® Construct new well O Use existing well
❑Replace existing well O Change or increase use 620 feet Lower Arapahoe
O Change source(aquifer) ❑ 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) 12.883 acres in the SW of the SE of Section 32,TIN,R65W,6th
Well permit# -_-_ _- . . -. . ---water Court case# --.__.. - - - P.M. (See Attached Map)
--- _
Designated Basin Determination* Well name
or#
4. Location Of Proposed Well
- .__.-_ ------- -- -- ------ —--- (If used for crop irrigation,attach a scaled map that shows irrigated area.)
County
Weld SW 1/4 of the SE 1/4 A. #Acres B. Owner ,
12.883 Don Sack
n Township NorS Range EorW Principal Meridian
1 ® O 65 O EC.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)
200 Ft from❑ N E S 2500 Ft.from E E❑W 9. Proposed Well Driller License#(optional):
For eplacement wells only distance and direction from old well to new well 10. Signature Of Applicant(s) Or Authorized Agent
feet direction ---- - - - ----- -
The making of false statements herein constitutes perjury in the second
Well location address(Include City,State,Zip) O check if well address is same as in Item 1. 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 signatu Date- --
Optional: GPS well location information in UTM format You must check GPS unit for Q I I�� 0
required settings as follows:
1
Format must be UTM Pn name if title34, 3 -)-1,.- 3', -yq- •
❑Zone 12 or O Zone 13 Easting L c17 T�c.ri�.
AJ2cIJ C-.GHT - fbSCcT rvtAnrl(�4A Units must be Meters
Datum must be NADSS Office Use Only
Northing
Unit must be set to true north USGS map name DWR map no. Surface elev.- --
Was GPS unit checked for above? O YES Remember to set Datum to NAD83
5. Parcel On Which Well Will Be Located Receipt
- -
areaonly - ---- -
(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A. Legal Description(may be provided as an attachment):
Lot A of RE-4578
12.883 acres in the SW of the SE of Section 32,TIN, R65W,6th
P.M. (See Attached Map)
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B. #of acres in parcel C. Owner WE
83 Donald Sack w4
Will this be the only well on this parcel? ONO(if no list other wells) CWCB
TOPO
E. State Parcel ID#(optional): MYLAR
SB5 DIV WD BA MD
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GWS-38(Rev.Sept 1996)
STATE OF COLORADO
OFFICE OF THE STATE ENGINEER
• DIVISION OF WATER RESOURCES
NONTRIBUTARY GROUND WATER CONSENT LANDOWNERSHIP STATEMENT
I (We) Donald Sack
(Name)
whose mailing address is 25880 E. 168th Avenue
Street
Brighton, CO 80603
(City) (State) (ZP)
claim and say that I (we) am (are) the owner(s) of the following described property consisting
of 12.8 acres in the County of Weld , State of
Colorado: (Insert Property Legal Description)
Lot A of RE-4578 described as follows: (See Attachment A)
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and that I (we) have granted written consent to others to withdraw ground water from the
Loeser Arapahoe aquifer as evidenced by the attached copy of a deed or
other document in the County or Counties in which the land is located, and that said ground
water has not been conveyed or reserved to another, nor has consent been given for
withdrawal by another except as indicated in the attached deed or other recorded document.
Further, I (we) claim and say that I (we) have read the statements made herein; know the
contents hereof;and that the same are true to my(our)own knowledge.
‘Cona /al .fac.,F
(Signature) (Date)
(Signature) (Date)
INSTRUCTIONS:
Please type or print neatly in black ink. This form may be reproduced by photocopy or word
processing means. See additional instructions on back.
• 1313 SHERMAN ST RM 818 DENVER CO 80203 (303)866-3581
ATTACHMENT A
The Southeast Quarter of Section 32,Except the North 210 feet of the Southeast
Quarter of Section 32 and except the East 210 feet of the Southeast Quarter of
Section 32, all in Township 1 North, Range 65 West of the 6th P.M., County of Weld,
State of Colorado
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