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Home My WebLink About20102737.tiff O 0 FORM N0., . PUMP INSTALLATI N AND TEST REPORT a For Office Use only GWS 32 " it/90 STATE OF COLORADO, OW OF THE STATE ENGINEER lirRECEIVED 1. WELL PERMIT NUMBER 96-VE-112 /95-19'2- 4 KAY 06 '96 •2. OWNER NAME(S) Latimer Bohlinq WATERRESOURC'S Mailing Address 105 WCR 251 STATEENGINEE? City, St. Zip Ft. Lupton, Co. 80621 Coto Phone (303 ) 654-0456 3. WELL LOCATION AS DRILLED: Nw 1/4 SE 1/4,Sec. 7 Twp. 2 N , Range A 6 rd DISTANCES FROM SEC. LINES: 2480 ft. from South Sec. line. and 1460 ft. from East Sec. line. ne ror south) (east or west) SUBDIVISION: LOT BLOCK FILING(UNIT) . STREET ADDRESS AT WELL LOCATION: . 4. PUMP DATA:Type Submersible Installation Completed 4-26-96 Pump Manufacturer Jacuzzi Pump Model No. 5S41088-S2 . Design GPM 15 at RPM 3600 HP 1 , Volts 230 , Full Load Amps 4. 9 . Pump Intake Depth 56 Feet, Drop/Column Pipe Size 1 " Inches, Kind PVC Sch 80 . ADDITIONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM: TURBINE DRIVER TYPE: ❑ Electric ❑ Engine ❑Other Design Head feet, Number of Stages , Shaft size inches. 5. OTHER EQUIPMENT: Airline Installed❑Yes No, Orifice Depth ft. . Monitor Tube Installed ❑Yes O No, Depth ft. Flow Meter Mfg. - Meter Serial No. Meter Readout❑Gallons, O Thousand Gallons, ❑ Acre feet, ❑ Beginning Reading „ .. TEST DATA: ❑Check box if Test data is submitted on Supplemental Form. Date 4-26-96 Total Well Depth 60 Time 3 :00 PM . Static Level 18 Rate (GPM) 15 Date Measured 4-22-96 Pumping Lvi. 22 7. DISINFECTION: Type HTH Amt Used 1# 8. Water Quality analysis available. ❑ Yes 0 No 9. Remarks J 10. I have read the statements made herein and know the contents thereof, and that they are true to my knowledge. [Pursuant to Section 24.4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.] CONTRACTOR R & R Well & Pump Inc. Phone (970) R53-1118 Lic. Na 857 . Mailing Address P n Box 577 Gree1y. Co 80637 Name/Title (Please type or print) Signature ' Date OWNER Glenn A. Clement - < � ' 5-2-96 `°""N°' . `" WELL CONSTRWON AND TEST REPORT • For Office Use only Gws.31 10/94 STATE OF COLORADO, IIIIPICE OF THE STATE ENGINEER �9'��I, 1 �� 1. WELL PERMIT NUMBER 96-VE-112 /9S/92-A Kir 06 `gg •2. OWNER NAME(S) Latimer Bohlinq WATER RESOUt?CEr Mailing Address 105 WCR 251 STATEEdiGtNEER City, St Zip Ft. Lupton, Co. 80621 0010 Phone (303 ) 654-0456 3. WELL LOCATION AS DRILLED: NW 1/4 SE 1/4,Sec. 7 Twp. 2 N , Range 66 W . DISTANCES FROM SEC. LINES: 2480 ft. from South Sec. line. and 1 460 ft. from East Sec. line. OR (norm or somn) (east or west SUBDIVISION: LOT BLOCK FILING(UNIT) STREET ADDRESS AT WELL LOCATION: 4. GROUND SURFACE ELEVATION ft. DRIWNG METHOD Rotary DATE COMPLETED 4-22-96 . TOTAL DEPTH 60 ft DEPTH COMPLETED 60 ft. 5. GEOLOGIC LOG: 6. HOLE DIAM. (in.) From (ft) To (ft) Depth Description of Material (Type,Size,Color,Water Location) 8 7/8 0 60 0-41 Top soil w/gravel mix 41-45 Coarse sand to 3/4 gravel X 45-52 Coarse sand to 2" gravel X • 52-60 Shale 7. PLAIN CASING OD (in) Kind Wall Size From(ft) To(ft) 6 5/8 Steel . 250 +1 20 5 PVC . 277 20 40 PERF. CASING: Screen Slot Size: . 035 . 5 PVC . 277 40 60 8. FILTER PACK: 9. PACKER PLACEMENT: Material Gravel Type Size 3/8 Interval Depth 10. GROUTING RECORD: Material Amount Density Interval Placement REMARKS: Cement 4 Bq. 1 . 86 0-20 Poured 11. DISINFECTION: Type 13TH Amt. Used 1# 12. WELL TEST DATA: ❑Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test. TESTING METHOD Bailed Static Level 18 ft. Date/Time measured 4-22-96 , Production Rate 1 5 gpm. Pumping level 22 ft. Date/Time measured 4-22-96 , Test length (hrs.) 14 . Remarks 13. i have read the statements made herein and know the contents thereof,and that they are true to my knowledge. [Pursuant to Section 24-4-104 (13)(a) C.R.S.,the making of false statements herein constitutes perjury in the second degree end is punishable as a class 1 misdemeanor.] • CONTRACTOR R & R Well & Pump Inc. Phone ( 970) 353-3118 Lie. No. 857 MaiiinaAddress P.O. box 577 Greeley. Co. 80632 . Name/Title (Please type or print) Signature Date _. OWNER Glenn A. Clement 5-2-96 Form o. ENGINEER .GWS-25 COLORADO DMSOI OF WATER RESOURCES • 818 Centennial Bldg., 1313 Sherman St, Denver,Colorado 80203 (303) 868-3581 857 • ' WELL PERMIT NUMBER 195192 - -4 APPLICANT DIV. 1 CNTY. 62 WD 2 DES. BASIN MD Lot: Block: Filing: SubdW: APPROVED WELL LOCATION WELD COUNTY LATIMER BOHUNG NW 1/4 SE 1/4 Section 7 10501 WCR 35 1/2 Twp 2 N RANGE 66 W 6th P.M. FT LUPTON CO 80621- DISTANCES FROM SECTION LINES (303)654-0456 2480 Ft. from South Section Line PERMIT TO CONSTRUCT A WELL 1460 Ft. from East Section Line • ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT CONDmONS OF APPROVAL 1) This well shall be used In such a way as to cause no material injury to existing water rights. The issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action. 2) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 18. • 3) Approved pursuant to CRS 37-92-602(3)(c)for the relocation of an existing well, permit no. Mr/94e The old well must be plugged and sealed according to the Water Well Construction Rules within ninety (90) days of completion of the new well. The enclosed Well Abandonment Report form must be completed and submitted to affirm that the old well was properly plugged and sealed 4) The use of ground water from this well Is limited to ordinary household purposes inside one (1) single family dwelling,the watering of domestic animals,and the irrigation of not more than 15,000 square feet of home gardens and lawns. 5) The depth of this well shall not exceed 60 feet or the depth at which sandstone or shale layer is first encountered, whichever comes first. 6) The maximum pumping rate shall not exceed 15 GPM. 7) This well shall be constructed not more than 200 feet from the location specified on this permit. 9b APPROVED 11Lae.• GLR gal U • -419 e Receipt No. 0399351 B DATE ISSUED MAY 2 2 1996 EXPIRATION lD �TE MAY 2 2 1998 FORM No: STATE OF COLORADO For ffice Use only GWS12N /1S-792.- 10/B9 OFFICE OF THE STATE�INEER p IT NUMBER 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 (3031888-3581 . REGISTRATION OF DECREED EXISTING WELL • PURSUANT TO C.R.S.37-92-304(8) 1. WELL OWNER NAME(S): Latimer Bohling Mailing Address: 10501 WCR 35 1/2 City, St. Zip: Ft. Lupton CO 80621 Phone: (303) 654-0456 .g"Us?AI 2. WELL LOCATION COUNTY: Weld OWNER'S WELL DESIGNATION: Johnson Well No. 1 (Address) (City) (State) (Zip) NW1/4 of the SE1/4, Section 7, Township 2 North, Range 66 West, 6th P.M. Distances from Section Lines: 2450 feet from the South Section Line; 1465 feet from the East Section Line. . 3. The well has historically been used for the following purpose(s): domestic 4. Water from the well was first used beneficially by the original owner for the above described purpose(s) on March 2, 1920. 5. The total depth of this well is 30 feet. 6. The pumping rate is 0.03 cfs (13.5 gallons per minute). •7. The average annual amount of water diverted is unknown. 8. The land area irrigated from this well is: unknown. FOR OFFICE USE ONLY IN ACCORDANCE WITH THE PROVISIONS OF SECTION 37-92-304(8), CRS,THE STATE ENGINEER HAS ENTERED INTO HIS RECORDS, UNDER THE ABOVE ASSIGNED WELL PERMIT NUMBER, THE DETERMINATIONS MADE BY THE DIVISION 1 WATER COURT IN CASE NO. W-6367 FOR WELL N0. 1. ,)qb ,cr9 Z • PA 61L, '°Ian) MAY 2 2 1926 State Engineer By Date Court Case No. W-6367 Div. 1 Co. 62 WD 02 Basin MD Use 8 • COLORADO DIVISION OF W. RESOURCESRECEIVED DEPARTMENT OF NATURAL OURCES /9"/-9.., 1313 SHERMAN ST.,RM.818,DENVER CO 80203 APR 17 '96 phone- info: (303) 866-3587 main: (303) 866-3581 WATER RESOURCES • RESIDENTIAL *Mote:You may also use this form to apply for syastoak watering) Water Well Permit A jJ ! WWor Review instructions prior to completing form Must be completed in black ink'or typed -1. APPLICANT INFORMATION 6. USE OF WELL (check appropriate entry or entries) name of applicant See Instructions to determine oasis)for which you may qualify— ❑A.Ordinary household use in one single-family dwelling Latimer Bohling US)outside use) "tailing Additive ® B. Ordinary household use in 1 to 3 single-family 10501 WCR 25 1/2 dwellings: Ntanber of dwellings: 1 an State rap cede 0 Home garden/lawn irrigation, not to exceed 1 acre: Ft. Lupton, CO 80621 .}� area irrigated 15000 LI sq. ft. ❑ acre Telephone renew(Include a . a) CJ Domestic animal watering —(non-commercial) 303-654-0456 2. TYPE OF APPLICATION (check applicable box(es)) r 0 C. Livestock watering (on farm/ranch/range/pasture) ❑ Construct new well ❑ Use existing well 7. WELL DATA C]` Replace existing well 0 Change/Increase Use Mmimun panpina nu AMISS ement to be withdrawn ❑ Change (source)aquifer ❑ Reapplication(e,mirad Fem.() 20 gpm 1 acre-feet ❑ Other: Taal depth Mum 3. REFER TO (if applicable)0 60 feet Alluvium Water court cases Permits 8. TYPE OF RESIDENTIAL SEWAGE SYSTEM Late Reg. ® Septic tank /absorption leach field -.. Verbal I Monitoring hole acknowledgment s ❑ Central system • -VE- MH- District name:Well name ors O Vault Location sewage to be hauled to: • 4. LOCATION OF WELL 0 Other(attach copy of engineering design) County Quarter/quarter Quarter 9. PROPOSED WELL DRILLER (optional) Weld NW % SE % Name License number Section TownshlpNors Range EorW PrIMMIMaidian R & R Well and Pump, Inc. 857 7 2 ® 0 66 O 13 6 10. SIGNATURE of applicants) or authorized agent Distance of well from section lines The making of false statements herein constitutes perjury 2480 h.from❑N E1 S 1460 h-from MEOW in the second degree, which is punishable as a class 1 mis- wslocation addreet If differenthe".nl.oanteddrmardapplicable) demeanor pursuant to C.R.S. 24-4-104(13)(a). I have read the statements herein, know the contents thereof and state For replacement welt only-distance end direction from old wall to new wee that they are true to my knowledge. 50 feet NE direction Mut "✓elan'°'' 5.TRACT ON WHICH WELL WILL BE LOCATED Q A. You must check one of trot following-see instructions \ Data ❑ Subdivision: Name Owner 51/..1—!/ c74 Lot no. Block no. Filing/Unit OPTIONAL INFORMATION O Count)/exemption (attach copy of county approval&survey) USGS map name DWR may no. Surface ea. Name/no. Tract no. .2-3—K 0 Mining claim(attach copy of deed or survey) Office Use Only Name/no. Wc. DIV I 0Other(attach legal description to application)3CR351 6 t I LI co S. STATE PARCEL F`6 ID#(optional): v easpf WD Oat c. #acme in tract D. Are you the owner of this property? • 41 . 505 OYES ❑ NO (if no- see instructions) BA E. Will this be the only well on this tract? OYES ® NO (if other wells are on this tract-see instructions) USE MD Form GWS-44 (11/95) FORM NO. -STATE OF COLORADO For ffice Use only cws-1z OFFICE OF THE STATE E ER 10/89 NUMBER 818 Centennial Bldg., 1313 Sherm t.,Denver,Colorado 80203 (303) 866-3581 0 v FOR.INSTRUCTIONS SEE REVERSE SIDE • REGISTRATION OF EXISTING WELL 1. WELL OWNER P,k_." NAME(S) Latimer Bohlinq u Mailing Address 10501 WCR 35 1/2 RECEIVE( City, St. Zip Ft. Lupton. CO 80621 ~ Phone ( 303 ) 654-0456 Y APR 1 7 '9f Receipt No. Ise z N = WATER R uSOviC ST'1TE 2. WELL LOCATION: COUNTY Weld OWNER'S WELL DESIGNATION COLD (Address) (City) (State)nn (Zip) NW 1/4 of the SE 1/4, Sec. 7 Twp. 2 ®N. or❑S., Range 6 6 ❑E. Of LXJ W. 6 P.M. Distances from Section Lines 24 4 0 Ft. from❑N. or©S. Line, 1 480 Ft. from ID E. or❑W. Line. 3. The well has historically been used for the following purpose(s): Household, lawn and garden irrigation, watering of farm livestock. 4. Water from the well was first used beneficially by the original owner for the above described purpose(s) on April 1 19 04, • 5. The total depth of this well is 3 0 feet. 6. The pumping rate is 20 gallons per minute. 7. The average annual amount of water diverted is 1 acre feet. 8. The land area of home lawn and garden irrigated from this well is: 1 5 0 0 0 O Acre or X Square feet, (Number) described as: Part of the NW1/4,SE1 /4 ,Sect . 7, TwpaN, Rng 66W • (legal pbon) or as Subdivision Lot(s) Block Filing/Unit I (we) have read the statements made herein, know the contents thereof, and state that they are true to my (our) knowledge. [Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second degree and is punishable as a Class 1 misdemeanor.] 9. Name/Title (Please type or print) Signature Date Latimer Bob]inq—Owner ifit; i-ii-9g) FOR OFFICE USE ONLY • State Engineer By Date Court Case No. _ Div. Co. 6a WD OQ Basin MD Use • • y , • t-MRT•S:Rn.76 COLORADO DIVISION OF WATER RESOURCES ..-"k 818 Centennial Bldg., 1313 Sherman St.,Denver,Colorado 80 3 • PERMIT APPLICATION FORM RECEIVED Application must FEBbe complete where I 1 A PERMIT TO USE GROUND WATER EB 1 6 applicable. Type or I 1 A PERMIT TO CONSTRUCT A WELL print in BLACK FOR: ( 1 A PERMIT TO INSTALL A PUMP 0014 IMMO. INK•No overstrikes ��0 a.. or erasures unless ( REPLACEMENT FOR N0. initialed, 1 OTHER , 6 �� WATER COURT CASE NO. (1) APPLICANT • mailing address ,�y1 IC€c�ILSE DNI OT 9a jE IN THIS COLUMN NAME OctJ r 1 P. I l B`€Gt f' $0 /l •/1 Receipt No. a3.Ge..ta 4 / j�t(f' STREET. 1050 I \-Ai G..R• s=. `5J Basin Dist. CITYAK7 A uptn Gr'/rj (O6°11 CONDITIONS OF APPROVAL t (State) �f (ZIP) TELEPHONE NO. 4 7� GV a This well shall be used in such a way as to cause no material injury to existing water rights. The (2) LOCATION OF PROPOSED WELL issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water County . jtk/q ' right from seeking relief in a civil court actionn ii . 1� �q//� Y. of the „S-7.... '4,Section A PROVED AS A REFM ACEMENT OF WEIl NO.A , J • Two,____ /11/R n9 -� z p M THE EXISTING WELL MUST BE PLUGGED AND ABANDONED in s) LE" ACCORDING TO THE REVISED AND AMENDED RULES AND REGULATIONS FOR WATER WELL ANJ PUMP INSTALLATION • IS) WATER USE AND WELL DATA CONTRACTORS. THE ENCLOSED AFFIDAVIT MUST BE Proposed maximum pumping rate (gpml 4�' SUBMITTED WITHIN SIXTY (60) DAYS AFTER THE CONSTRU 1 N 0. THE NEW WELL,AFFIRMING THAI) WELL NO 4$ WAS PLUGGED AND ABANDONED. Average annual amount of ground water to be appropriated (acre•feetl: Are r... YET 1"JNICYI 11 CO?r t t C07 ^'t^!'?l Number of acres to be irrigated: / SHALL BE COIiSr1L1'n V; k''i lx:?'.?..',.^0 //� THIS WELL, MID THL''R FISG(L1:TIONS Proposed total depth (feet?: V`"� SHALL BE COMPLIED WITH. Aquifer ground water is to be obtained from: Owner's well designation GROUND WATER TO BE USED FOR: ( 1 HOUSEHOLD USE ONLY . no irrigation (0) (7k,) DOMESTIC (11 ( I INDUSTRIAL (51 1 LIVESTOCK (2) ( ) IRRIGATION (61 ( I COMMERCIAL (4) ( MUNICIPAL (SI ( I OTHER (91 APPLICATION APPROVED DETAIL THE USE ON BACK IN (11) 124133�IQ PERMIT NUMBER. (4) DRILLER ,� J --7^" DATE ISSUED FEB 2 61982 Name 42 `�`�/ +" R '`P /1 .. A..4.. A..4--n • EXPIRATION IRTI DATE FEB 2 61984 • Street / 95 IC/A s/�y, l A •. GI P, 7.! IU ,96'6 / I ISTVE GI City / (Stall') (ZIP) ASS Sta.) 3 r73' 3//y` BYf Telephone No. Lic. No. 62 I.D. J r , - o COUNTY • • • .r (5) THE LOCATION OF THg PROPOSED WELL and the area on (6) THE WELL MUST BE LOCATED BELOW which the water will be used must be indicated on the diagram below. by distances from section lines. • Use the CENT,fi<SECTION 11 section, 640 acres) for the well location, ' I a Vr l ft. from sec,line } �.Iy ss r . ' — '4" _I + — _4— — 4 _ _4' _ "'t' '/Ov north or soutnl "T ♦ H isii. t `r` I 's�", iii • it 1 MILEk,628o FEET--pl I , �b w ft. from F sac.line II ,� t + (east or west) let ,r. T ± 1, + • + ± -4. LOT BLOCK FILING • SUBDIVISION '4- — I TRTHSECTIONLINE (7) TRACT ON WHICH WELL WILL BE I LOCATED Ownerl�r� YS a '7 NORTH '(" 3 "" +' — + — -'3 + t No. of acres 4,7 . Will this be o o m H ' the only well on this tract?_ d I a + us I o — + (8) PROPOSED CASING PROGRAM I / z Plain Cas�i�ngg .4— ; +_ _ _ 7 _ + _ -m + T .k Y._in.from 0 ft.to .5—b ft. I I I I 4`7294„,,from O2O ft,to—a—ft. I i I ,_ _4_ - 4 Perforated casing SOUTH SECTION LINE I I _ 4'/tin, fromY O ft.to b 0 ft. + + + + 4 + 4 4 + in, tram ft.to i `t. (9) FOR REPLACEMENT WELL$givedistance and direction from old well and plans for plugging • The scale of the diagram is 2 inches= 1 mile 6PF'f" S D�G/ ale // Each small square represents 40 acres, T WATER EQUIVALENTS TABLE (Rounded Figures) y 7-e , ,Q An acre'foot covers 1 acre of lend 1 foot deep (// �l K U p 1 cubic foot per second(cfs) . . .449 gallons per minute wpm; k_ lit / 5 A family of 5 will require approximately 1 acre-foot of water per year. ii $ C I P 1 acre'foot.. .43.560 cubic feet . . .325,900 gallons. 1,000 gpm Dumped continuously for one day produces 4.42 acre feet. (10) LAND ON WHICH GROUND WATER WILL BE USED: • Owner(sl: 4 lest No. of acres. Legal description: (11) DETAILED DESCRIPTION of the use of ground water: House old use and domestic w,efis must indicate type of disposal system to be used. rjnfas,7 h S,G/G - rt. y,s',4•% re y7 f 'C (12) OTHER WATER RIGHTS used on this land, including wells. Give Registration and Water Court Case Numbers. Type or right Used for(purpose) Description of land on which used (13) THE APP tCANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS TRUE THE BEST OF HIS KNOWLEDGE. •/ ,SIGNATURE OF APPLICANTIS) Use additional sheets of paper if more space is required. _ S - - -. . w426:7, • pr ,r r COLORADO DIVISION OF WATER RESOURCES• • ftat' i "ED THIS FORM MUST BE SUBMITTED 1313 Sherman Street • Room 818 MAR 2 9 1982 i • WITHIN G11-SAYS OF COMPLETION Denver, Colorado 80203 of THE WORK DESCRIBED HERE• • WrATEg RLSOIIaC� ON.TYPE OR PRINT IN BLACK WELL COMPLETION AND PUMP INSTALLATION REPO tT Ea Emma INK. PERMIT NUMBER 124133-A fk WELL OWNER Darrell Bearson NW v.of the SE %of Sec. 7 ADDRESS10501 Weld Co. Rd. 25& Ft. Lupton. CO T. 2 N , R. 66 W 6 v DATE COMPLETED February 17 , 19 82- HOLE DIAMETER 8 3/4 in. from 0 to 52 ft. WELL LOG Water in. from to ft. From To Type and Color of Material Loc. in. from to ft. 0 3 top soil DRILLING METHOD Rotary 3 6 sand • CASING RECORD: Plain Casing 6 15 coarse sand 8. pea gravel mix 15 18 pea gravel/small gravel X Size 5" & kind Plastic from 4 1 to 32 18 22 coarse sand X 22 26 pea gravel & small gravel X Size & kind from . to 26 31: pea gravel & coarse sand X 31 38 pea gravel/gravel rocks X Size & kind from toL 38 42' pea gravel/small gravel X 42 4& gravel 8. rocks X Perforated Casing 46 47 hard brown sandy clay 47 52 shale Size 5" & kind Plastic from to 52 • Size & kind from to Size --& kind from to GROUTING RECORD Material cement Intervals 0 to t0 ft. Placement Method poured GRAVEL PACK: Size pea Interval 10 to 52 ft. TEST DATA Date Tested February 17 , 19 . Static Water Level Prior to Test 15 Type of Test Pump Bailer Length of Test 1 hr. • Sustained Yield (Metered) 15 qpm TOTAL DEPTH 52 ft. Use additional pages necessary to complete log. Final Pumping Water Level 17 ft. • --. ,- • • wRY•adae"' COLORADO DIVISION OF WATER RESOURCES OR 818 Centennial Bldg„ 1313 Sherman St. IN7 IN BLACK INN. OPY OF ACCEPTED Denver, Colorado 80203 STATEMENT MAILED ON REQUEST. STATE OF COLORADO AFFIDAVIT SS COUNTY OF _ _ — STATEMENT OF BENEFICIAL USE OF GROUND WATER AMENDMENT OF EXISTING RECORD LATE REGISTRATION PERMIT NUMBER 12 'u33 LOCATION OF WELL THE AFFIANT(S) _ _ ._Rolland A. Johnson Count Weld whose mailing + 7.. S ar o �— address is ...._ ._-- Route 2 —.—_—._.. NW 7. Di the City Ft. Lupton, Colorado 80621 2 N 66 W 6 PM . Ro .--_ — being duly sworn upon oath, deposes and says that he (they) is (ore) the owner(s) of the well described hereon, the well is located as described above, at distances of _ 2240, feet from the Slab MItb section line and 2510 feet from:the East section line, water from this well was first'applied to o beneficial use for the purpose(s) described herein on the 31 u.f. L4 Al ill day of July , 19 11-6, ; the maximum sustained pumping rote of the well is 13 gallons per minute, the pumping lite claimed hereby is __AL__ gallons per minute, the total depth of the well is 35 _feet; the overage annual amount of water to be diverted is acre-feet; for which claim is hereby made for Domestic — purpose(s), the legal description of the land on which the water from this well is used is of which acres ore irrigated and which is illustrated on the mop on the reverse side of this form; that this well was completed in compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he (they) has (have) read the statements mode hereon; knows the content thereof; and that the same are true of his (their) knowledge. (COMPLETE REVERSE SIDE OF THIS FORM) Signature(s) �..__—.___ ------- FOR OFFICE USE ONLY Subscribed and sworn to before me on this day of _ , 19 --- W-6367-2 Cou,r Cost No — -...._. . My Commission expires) P.�or. _ Mo Do✓ Y, - -. Div. Cry. . ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO iCietklitnkingirttilaiOLLOWING CONDITIONS, BY TEE OFFICE OF --- TEE STATE ENGINEER ACOORDTNG TO THE D,,, Ba„ _ Mnn o„ DECR�i GRANTED UNDER Ode INFER '1-/J-,8 Z- AKENo.79.6,35-% ,w ER DIVISION / w, PURSUANT TO SECTION 37-92-304 .(8) ,, C8$ 1973. _.v, Y��i�fE 2 6 1982 c,ATr c-N G7NEFa_..___. . •Accela Automation: GetPerSet 108150-S • Page 1 of 2 Menu I Favorites I Help I Logout • ' Weld County, Colorado q User ID: MSWAIN * ACCE SmartManager Application f Property if People F Fees Cashier 1 Workflow Attachments Inspection Rep Application - Summary Application Type: Health/ EHS History/EHS Conversion History/NA Application: G19840209 Owner Name: BEARSON DARRELL Owner Address: 10501 WCR 25.5, FORT LUPTON, CO 80621 Address: 10501 CR 25.5 , WELD, CO Application Comments: Comments Application Status: Finaled Parcel No.: 130907 File Date: 11/14/1984 Description of Work: Application Spec Info.: Base Information Eng Design Req'd: N Engineer: 2 HOMES ON SAME SYSTEM • FEE PAID: N Filing: 000 Final Date: 12/13/1984 Final Date Text: 0271 In 100 Yr Flood Plain: N Installer: 1001 Issued Date: 11/14/1984 • Issued Text: 0253 Location: 10501 WCR 25.5 FORT LUPTON CO 80621 Lot Size: 42 Owner/Agent: REHA BEARSON PERMIT FEE: 0 Perc Date: 11/14/1984 Permit No: 209 Sec/Twn/Rngl: 07 Sec/Twn/Rng2: 02 Sec/Twn/Rng3: 66 Signed Date: 11/14/1984 Signed Date Text: 0010 Status: A System Type: T Type: R Year: 1984 Services/Installation # of Bedrooms: 1 # of Persons: 2 Basement Plumbing: N Bathrooms: 1 • Bed: Y Bed Size SQFT: 300 Commercial: N Ground Slope: 0 https://accela-web.co.weld.co.us/operations/permit/index.cfm?FUS EACTION=GetPerSet2... 9/29/2009 Accela Automation: GetPerSet. 8150-S • Page 2 of 2 Institution: N Other: N • Percolation Rate: .011 Residential: Y Soil Suitable (S/U): S Tank Capacity Gal: 1250 Trench: N Trench Size SQFT: 0 Water Supply: PWELL Application Spec Info. Table: Application Detail: Detail Contact Info: Licensed Professionals Info.: Job Value: $0.00 Total Fee Assessed: $0.00 Total Fee Invoiced: $0.00 Balance: $0.00 Workflow Status: Task Status Status Date NA • Condition Status: Condition Name Status Apply Date https://accela-web.co.weld.co.us/operations/permit/index.cfm?FUSEACTION=GetPerSet2... 9/29/2009 • q qc ,oci • fr' rV :e *APPLICATION OR INDIVIDUAL SEWAGE DISPOSAL SYSTEM • WELD COUNTY HEALTH DEPARTMENT Nev, KIP ENVIFONMENTAL HEALTH SERVICES 1516 Hospital Road, Greeley, CO 80631 / Repair 353-0540 EXT. 270 7 BP _ � Ch Ot',^ILR�k{((c�._ ��Qi ±ft. ADDRESS /C`-GL_L.(.'(./ 2S�z r" . .LIaHONE t''. :L"1'- ADDRFSS OF PROPOSED SYSTEM Sy+N, i` I LEGAL DESCRIPTION OF SITE: PT .c)F Q S._ 9 , T_ 2 , RGi SUBDIVISION _ � LOT BLOCK , FILING _ / / USE TYPE. RESIDENTIAL /- /%''.tint^ Armes P INSTITUTION__ COMMERCIAL .- OTHER I SERVICES. PEP..SONS_ / BATHR')OMS / LOT SIZE 7�/.2 Qzt/'P S BEDROOMS EASEMENT PLUMBING flip` / WATE/RSUPPLY .({ //f /7 TYPE OF SEWAGE DISPOSAL REQUESTED: ✓T�/ I (I_ / Or1/C ,f-- !p410A P 'F/P Appl,cani acknowledges that the completeness of this ppiication is conditional upon further mandatory and additional tests and reports as may be required by the Weld Doi..my Health Department to be made and furnished by the applicant or by the Weld County Health Department for purposes o' the evaluation of the application; and the issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations adopted under Article 10, Title 25, CRS 1973. as amended. The applicant certifies that the proposed system will not be located within 400 feet of a com- munity sewage system. The undersigned hereby certifies that all statements made, information and reports submitted here. with and required to be submitted by the applicant are, or will be, represented to be true and correct to the best of my knowl- edge and belief. and are designed to be relied on by the Weld County Health Department in evaluating the same for purposes of issuing the permit applied tor herein. I further understand that any falsification or misrepresentation may result in the denial of the application or revocatiog of any permit granted based upon said pplicatlon and in legal action for perjury as provided by law. /��- ✓Applicahop�tee / ,for ��1'��..orn �� Recd by/ 'A b Lieu` �//fat Date-2 - ' _ Owner/Agent Signature Date • J -..--- J,a FOR DEPT. PERCOLATI RATE_ AO WATER TABLE DEPTH /: USE ONLY SOIL TYP tir -Oi re— P"erne t 'P t ERCENT GROUND SLOPE REQUIRES ENGINEER DESIGN ( ) YES$No / • INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT From the application Information supplied and the on-site soli percolation data, the followingFilnimurrimstallatron specifi- cations are required: / SEPTIC TANK ,,/,)‘)O G<.LLONS, ABSORPTION TRENCH 33 O SO FT. 11;O or ABSORPTION BED / ;U SQ FT. In addrli Permit is uP ct to the folio additional ms and conditions: 7 P 4j uThis Permit is granted temporarily Le allow construction to co mance. This Permit y be revoked or suspended by the Weid.4 County Health Department tor reasons set forth Ir the Weld County Individual Sewage Dispose, System Regulations.including failure to meet any term or condition imposed the•eon Curing temporary or final approval. The'nuance of this Permit does not constitute assumption by the Department or its employees of ha for tall e or miadep of the sewage disposal ysr __ t�/gyp/OQf O moron al Spec:al:5f ba e This Permit is not transferrable and shall become void It syst construction has not commenCeC within One year 01 its issuance Bet're issuing final approval of this Permit the Weld County Health Department reserves the right to impost addibona,. fermi, and conditions required to meet our regulations 01 a continuing basis Finai Permit approval r5 cent:ggent upon the i.r„' LL..- s.ec lion of the completed system Dv the Weld County Health Department. — . ,ei--!. - -4, .-- - -i..- -1--- 7- - -'a-- G+_ I.La." ..e t- -a-c , CYST NE CONTRACTOR FINAL INSPE iii / rl / /. gcc-f c ucEA APPROVAL • /?�+1+'�' � . - cyi C�L ' '. -- - __. _. — �nvrronmeMs Spt a ..• Laii • Tr' 1,-'7,,' COe r 't imp,, COmp'.ianCe with others ate. county or loco rew aic,. 0' bu id r. rt0u rt'^t' " ,. a-. .1 r': ^ '.' 3' the-S..72 e:71m s.c a' e ' stSte w.it operate in compliance with appab•e ete count, ant. loch' re.,;_d -, , : . •S..a"..-'. ..:.e C. 7 ..e 2°. CPS 197: as amended except to' the purposes 0' e:lat 'shin; I,ra app'u.a c- a' ,• 'e... s.,a^re c' a •-:a• occuparc perm'!: owsuan' to CRS 1573 25.15 7'1 ;2 . . :3't L . .,_ _ v;t'-1✓--E.'_. F er;ruier "!t": Hello