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WATER SUPPLY INFORMATION SUMMARY
Section 30.28-133,Id1, C.R.S. requires that the applicant submit to the County;Adequate evidence that a water supply that
is sufficient in terms of quantity, quality and dependability will be available to ensure an adequate supply of water.
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1. NAME OF DEVELOPMENT AS PROPOSED �� JJ
2. LAND USE ACTION K) Q t,O Salt ' L —(0.A.,14/1A ) J A4 t'
3. NAME OF EXISTING PARCEL AS RECORDED o 6
SUBDIVISION FILING BLOCK LOT
4. TOTAL ACREAGE f 5. NUMBER OF LOTS PROPOSED f PLAT MAP ENCLOSED'AYES
6. PARCEL HISTORY- Please attach copies of deeds, plats or other evidence or documentation.
A. Was parcel recorded with county prior to June 1, 1972? 0 YES -NO
6. Has the parcel ever been part of a divi ' n of land action since June 1, 1972? DELYES 0 NO
If yes, describe the previous action
7. LOCATION OF PARCEL - Include a map deliniatmq the project area and tie toto a section corner.
L
1/4 OF 1/4 SECTION TOWNSHIP 0N ❑ S RANGE ❑ E A W
PRINCIPAL MERIDIAN: 4 6TH 0 1s.M. 0 UTE 0 COSTILLA
8. PLAT• Location of all wells on property must be plotted and permit numbers provided.
Surveyors plat %Yes 0 No If not, scaled hand drawn sketch 0 Yes 0 No
•9. ESTIMATED WATER REQUIREMENTS - Gallons per Day or Ace Feet per Year 10. WATER SUPPLY SOURCE
❑ EXISTING 0 DEVELOPED 0 NEW WELLS -
WELLS SPRING PROPOSED AQUIFERS_(CHECK OK
HOUSEHOLD USE A of units GPO AF WELL PERMIT NUMBERS ❑ALUM 0 uRER ARAPAHOE
❑UPPER DAWSON 0 ONO ARAPAHOE
COMMERCIAL USE # of S.F. GPO AF 0 LOWER DAMON ❑LARANO Fns Nus
❑OMER ❑DAKOTA
❑OTHER
IRRIGATION # of acres GPO AF
STOCK WATERING # of head GPD AF 0 MUNICIPAL
O ASSOCIATION WATER COURT DECREE CASE NO.'S
OTHER - GPO AF 0 COMPANY
O DISTRICT
TOTAL GPO AF NAME
LETTER OF COMMITMENT FOR
SERVICE 0 YES 0 NO
11. ENGINEER'S WATER SUPPLY REPORT ❑ YES 0 NO IF YES, PLEASE FORWARD WITH THIS FORM. (The may be required before our review it completed!
12. TYPE OF SEWAGE DISPOSAL SYSTEM
O SEPTIC TANK/LEACH FIELD 0 CENTRAL SYSTEM • DISTRICT NAME
❑ LAGOON 0 VAULT • LOCATION SEWAGE HAULED TO
IlltENGINEERED SYSTEM (Much a copy of engineering SO 0 OTHER
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2011-0189
09/28/2010 11:31 3038571891 FOR A PRODUCE PAGE 01/01
Form No. OFFICE OF THE STATE ENGINEER
GWS-25 COLORADO DIVISION OF 1! R •RESOURCES . •
• 810 CwnMrNdN ab 1313 Shan fat parser.Worms 80203
• 069-35111 698
WELL PERMIT Monet 213861 -
A DIV. 1 WO2 DES.BASIN MD
I,at Aft* Pliny Subdiv:1909-1$4IE-4854
APPROVED WELL LOCATION
WELD COUNTY
NE 1/4 SE 1/4 Section 19
RANDALL ANDERS Township 2 N Range 86 W Sbch P.M.
8443 HWY 8¢ QISTANCES FROM SECTION LINES
FORT LUPTON,CO 80821- 2374 FL from South Section Lk*
152 Ft from East Section line
.—._ -{303}8572168 — --�•--- .- '- -- -
3,NA083)----
PERMIT TO ceNSTRLKOLA WELL - - Fasting: Northing:
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT -
CONDITIONS OF APPROVAL
1) This wee shall be used in such a way as to came no material injury b misting water rights. The issuance of this permit
does not ensure that no bgtay will occur to another waled flier:right or padude another caner of a vested water right from -
seeking relief n a ahrl court action.
2) The'oomtn+ction of this well shall ben compliance with Ole Water Weil Construction Rules 2 CCR 402-2,unless approval
of a variance has been wanted by the State Dowd of Examiners of Water Wee Construction and Pump Instakdon
Contractors in accordance with Rue 18.
3) Approved pursuant to CRS 37-92-W21lX1)and poky of be Slate Engineer under the blowing meadow for a 12 aae
alltparcel known as Lot A.County Exemption m.1309-19-4 RS4864,Weld County.
The use of wound water front as wee is ended taordlrra y household pureness inside Moo(2)single burly dwwa"gs,
the watering of nd more then bur(4)-lags noncomreraid domestic wane*and be Irrigation of not more than 41,000 .
• aquas feet athome gardens and lawns.
6) Production born Unwell is restricted to the Laramie Fox Fees agWbr,which awnespords to the interval between 310 feet
and 680 fest below the glad surface. Maks seem shrine installed and grouted to prevent production tom other zones.
' 6) The psepng nab of this well shall not aced 15 GPM.
7) The anal stews of grand wabrfrom this well dal not exceed 2.1 ant
8) 'The well conabuded under permit no.278884 neat be plugged in accordance with Rude 18 of the Water Wee
Construction Ruleswaie ninety(90)days ef Qo4pled00 of the nag well. The wrgioeed Wel Abaidorme t Report tom!
must be submitted to shim thet the old seal was pugged.
9) The use Otitis peen hereby cancels permit no.278864.
10) The return pow from the use of this seal mud be bough an ndviduel waste mid disposal system tithe type so that not
less than 2%of the total amount ofwater withdrawn is retuned to the samostrearm system in Wilt the wet is located.
11) This well said be constructed not mom gum 200 fest from the location specified on this porn* .
12)' The depth to the top of the Laramie-Fat Has aquifer Is apen:alma To enure the antltaion of poor quality watt from
' zones it medately above the aquifer,Sin basin and grog anal extend through the lowermost dot ardor carbonaceous
share that overlies the Lammie sand portion 0the aquifer. -
NOTE:The ability of this well to withdraw its!Sharked assent dweller from Shia non-renewable aquifer army be less than
the 100 yews upon which the amount of woMan the aquifer isallocated,this to arredpaled water level declines_
To inane a m wdmum productive We of tts well,perforated casing should be set through �oducfn�
interval of the anxraved zone or aquifer indicated above-
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VED
ens
,Recebt No.3846472 DATE ISSUED 010 . erg PIRATIO ► II' h -2012
! . •
GWS-I3A S-I3A(01/2007)
COLORADO DIVISION OF WATER RESOURCES FIELD INSPECTION REPOR'pECEIVED
IIIPlease complete this form in ink Application Receipt No(s):
DIV I WD 2 WELL STRUCTURE NO.(IF APPLICABLE): SEP 0 2 2008
DATE OF INSPECTION: r^ 22-of PURPOSE OF INSPECTION:LATE REG®OTHER 0
WATER COMMISSIONER NAME: gA2k was
PHONE NUMBER:i 97 )352.- f7/2 or(970 ,2 - 99 33
ErSJ OTC
APPLICANT: I�r1 Person contacted if not applicant: A„„dy e4.Jers
ADDRESS: ; 9 9��� g C
c4- °` ipteR $0421
PHONE: f 4-t0 1 540 -7'04 ext.
EXISTING��t/IS� WELL LOCATION: .
Ay.,..,of the 'G,of;env
1q_,Township-- .2- ® 4' �N or❑S,Range nE o,[9W, C-et. P.M.
Distance from section line .y/y ON or[ES,) C'A ®E or OW,County /4/LI
OPTIONAL INFORMATION(GPS unit must be set for f)i4D83 meters,and true north) Zone 12❑or 13 c0
Easting Si40 SG Northing f9<I I`f 3.O
Mark type of existing well: El drilled,0 hand dug,0 spring well,0 gallery well,❑gravel pit, [pother
Estimated date well constructed: /1/7 Date of first use: 12/7 Estimate pumping rate: //) GPM
Total number of acres in this tract/parcel: 12 acres
Address of property(if different from than the applicant address):
Additional subdivision/parcel information:
Number of non-exempt acres irrigated: Name of Aug. Plan?
• Any other wells located on this property?(yes)how many (no);permit 8,case N,use?
Use of Well:
Household use in(indicate how many)_ _single family dwelling(s)
Watering of poultry,domestic animals,and livestock—approximately how many head?
Watering of livestock only—approximately how many head? Is this�a feed lot?❑yes❑no
Estimated area of historical lawn and garden: ) ['Square feet feet 1�'acre of lawn and garden
❑Fire protection
❑Commercial—drinking&sanitary only?(write details in"comments"section)
❑Other(write details in"comments"section)
DOVES ONO WERE THE USES CHECKED ABOVE INITIATED PRIOR TO MAY 8, 1972?
NOTE: If ANY CHANGE IN HISTORIC USE OF THE WELL HAS OCCURRED SINCE MAY 8, 1972,please
. indicate the date(s)the use changed,and discuss this change/expansion of the current or proposed use in the
comments section of this form.
Signature of Water Commissioner: k^-cK.O L I Dated: 'der-O8
(NOTE:If filing electronically without a signature,please check the box.0)
Additional comments and/or information:
• More room for comments on the back
Page 2,FIELD INSPECTION REPORT
Form STATE OF COLORADO For Office Use Only
No. OFFICE OF THE STATE ENGINEER
OWS-12 818 Centennial Bldg., 1313 Sherman St..Denver, CO 80203 h\
62006 (303)866-3581 Fax(303)866-3589 ff
• http://rater.state.co.us/defaulthtm RECEIVED
REGISTRATION OF EXISTING WELL
NAME.ADDRESS AND PHONE OF THE WELL OWNER: SEP 0 2 2008
NAME(S) Ambers Brokers PoA-
iuerattrp Imams
MAILING ADDRESS
P.O. Box. 117
CITY: Lutanist CO
srACoo. ZIP CODE:
TELEPHONE NUMBER E-MAIL(OPTIONAL)
(970)5249- -7g24 11 RY <1A414Q rrS,O.con
WELL LOCATION County U e C Owners We Designation(optional)
%'443 i4WY tts F+• tpttA). Co 80621
(Address) (City) (State) (Zip)
a. 1/4 of the S E 1/4,sec. __,Twp. ®N.or❑S., Range) ❑E.or®W., 64, P.M.
Distance from Section Lines 251'} Ft.❑N.or I S.Line, 15Z Ft M E.or❑W.Line.
PLEASE ATTACH A COPY OF A CURRENT DEED FOR THE SUBJECT PARCEL
Subdivision Name ,Lot_, Block . Filing/Unit
Optional: GPS well location intimation in Ji M format The following GPS settings are required: awing 51 LO RG,
Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true
north. ❑Zone 12 or 15 Zone 13
Northing 414444 zo
Was GPS unit chedked for above items?❑YES El NO
(`�
• The well has historically been tt used for the following purpose(s):
r4ou:se 1,15 Lk YOMesLc use i Q,nrrl haat u .
Water from the well was first used beneficially by the original owner for the above described purposes on iq I
The total depth of this well is An feet
The pumping rate of this well is V gallons per minute.
The average annual amount of water diverted is I acre-feet.
The lawn and garden irrigated(watered)by water from this well is /OooD 0 Acre or I?g Square feet
Number
The making of false statements herein constitutes perjury in the second degree,which is punishable as a class 1 misdemeanor pursuant to
C.R.S.23-3-104(13)(a). I have read the statements herein,know the contents thereof,and state that they are true to my knowledge.
Signature(s)of the Well Owner Print Name and Title of Well Owner Date
: erg J Pa - _'tsLr 441Aers Broi .ers Par4a esLp enim loss
-T-�,.._ Gestated Porboar Bahr, •m.. /,._,dery os(za(of
/ 7 IA C. / For Office Use Only
WE l// /i
Trans Number;3632868
WR 912/200810:0453 AM
Debbie Gonzales(20)
cwc6 1// Tetel TrMM Ant$1 X.00
\/ CHECK
• TOPO Chita Number. 5208
MOLAR DivujsiR100.00 MD
Form No.. OFFICE OF THE STATE ENGINEER
GWS-25 COLORADO DIVISION OF WATER RESOURCES
818 Centennial Bldg., 1313 Sherman St.,Denver,Colorado 80203
(303)866-3581 LR
• WELL PERMIT NUMBER 278664 - _
APPLICANT DIV. 1 WD2 DES. BASIN MD
APPROVED WELL LOCATION
WELD COUNTY
NE 1/4 SE 1/4 Section 19
ANDERS BROTHERS PARTNERSHIP Township 2 N Range 66 W Sixth P.M.
PO BOX 147 DISTANCES FROM SECTION LINES
LUCERNE, CO 80646- 2374 Ft. from South Section Line
152 Ft. from East Section Line
(970) 590-7429 UTM COORDINATES(Meters.Zone:13,NAD83)
REGISTRATION OF EXISTING WELL Easting: Northing:
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS 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 this permit
does not ensure 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) Construction details for this existing well have not been provided to this office;therefore,it is not known if the construction
of this well is in compliance with the Water Well Construction Rules,2 CCR 402-2. The issuance of this permit does not
relieve the well owner of responsibility or liability in the event contamination of the groundwater source results from the
construction or use of this well,nor does the State Engineer assume any responsibility or liability should contamination
occur. .
• 3) This well is recorded and permit approved in accordance with CRS 37-92-602(5)for historical use as indicated herein
and described in CRS 37-92-602(1)(b),being a well producing 8 GPM and used for ordinary household purposes inside
one single family dwelling,fire protection,the watering of domestic animals and poultry,and the irrigation of not more than
1/2 acre of home gardens and lawns.
4) The date of first beneficial use,as claimed by the applicant,is December 31st, 1917.
NOTICE:This permit has been approved for the irrigation of 1/2 an acre of home gardens and lawns as indicated on the
Field Inspection Report. You are hereby notified that you have the right to appeal the issuance of this permit, by filing a
written request with this office within sixty(60)days of the date pf issuance, pursuant to the State Administrative Procedures
Act. (See Section 24-4-104 through 106,C.R.S.) VD.N. O91Rapt
ap{
APPROVED W
D jte', . 1r
Receipt No.3632868 DATE ISSUED 09-16-2008 EXPIRATION DATE 09-16-2010
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