HomeMy WebLinkAbout20191116.tiffScanning Cover Sheet
for
Septic Permits
Permit # '
Permit Type:
Situs Street Address
Situs City, State, Zip
G19722107
Health 1 EHS History f EHS Conversion History
45254 CR 81
Sec/Town/Range: 14 -08N -62W
Parcel # (12 digits)
Owner Full Name:
Owner Address:
Contact Name:
Contact Address:
054514000002-R0565686
FREEMAN VAN
2E. 1 3/4 NORTH.
BRIGGSDALE,CO 80611
Application Status: Finaled
Application Date: 03/11/1996
Owner Phone #: 303 6562423
Contact Phone#
Information above has been Verified in Accela by employee noted below
Pr sled by: Pro essed by:
April 06, 2009
Date .
Report ID: EHS00024v003
Print Date -Time: 4/6/2009 12:49:17PM
Page 1 of 1
tr
WELD COUNTY HEALTH DEPARTMENT
No. r I c
1555 17th Ave.
Greeley, Colorado
Application for Permit to Install, Construct, Alter or Repair
Ownerz7 Sponsor
elk,' •
Addr
A
Individual Sewage Disposal System.
Address -of Site
Mailing�Addres
OA -440
t -440 WI
Gen - . 1 Info;mation
1. Living Units
2. No. of Bedrooms
3. No. of Baths
4. Basement Drain
5. Automatic Dishwasher
6. Garbage Disposal
7. Automatic Laundry
8. Size of Lot
9. Type of Soil
10. Percolation Test - 1 a sl��Q jilts
11. Water Supply
12. Lot Grade
13. Water Table Depth
14. Other
t4S'asct e--‹ 8/
The Permit is to remain in full force and effect for six
2Tank
1. Liquid Capacity Gallons
2. Dimension
3. Material
4. Type Inlet
Type Outlet
Pyne
D
ndary Treatment
1. No. of distribution).*
2. Trench: Widt
3. Type Filler Material ‘.1"4,--7, �r
4. Depth of# `illert rial
5. Gravel Size
6. Type Tile 1"'4 L.yt
- 7. Depth of Cover
S. Other
(6) months from date, until revoked for non-compliance.
This system will be constructed in accordance with the above specifications and regulations governing non -
municipal sewage disposal systems, in accordance with Regulation No. 1 of the Weld County Health De-
partment.
Dat
The plans and specifications as shown are
The above system inspected and found to
Installed by
PERMIT FEE $
Received by
Please use reverse side
4,6
Applicant :
tp '411 -AAA)
approved, pending payme #f it_'fe�
Sanitarian "�"
v _
Date: f9y/7
comply with the plan and description.
Sanitarian:
Date:
Date
lot Plan or use se
arate sheet of paper.
oel(
i
Best copy Available
COLORADO DIVISION OF WATER RESOURCES Office Use Only
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER, CO 80203_
Main: (3031866-3581 Fax: (303) 866-2223 dwrpermitsonlinei state.00.us_
RESIDENTIAL Note: Also use this form to apply for livestock watering
Water Well Permit Application
Review form instructions prior to completing form.
Hand completed forms must be completed in black or blue ink or typed.
r 1. Applicant Information
wme[s)
'aka+
Form GWS-44 (7/2012)
RECEIVED
Nov 0 5 2013
)U?CEES
STATE
Mailing address
110 Oak-. Am.-
Oily
E,To il
Telephone {wlarea code) E-mail
r10 SL s—r�t- 32SI
2. Type Of Application (check applicable boxes)
o Construct new well
❑ Replace existing well
]Use existing well
❑ Change or increase use
3. Refer To (if applicable)
Zip code
lc
❑ Change source (aquifer)
❑ Reapplication (expired permit)
El Rooftop precip. collection
❑ Other:
6. Use Of Well (check applicable boxes)
Siinstructions to determine use(s) for which you may qualify
A. Ordinary household use in one single-family dwelling
(no outside use)
ig B. Ordinary household use in 1 to 3 single-family dwellings:
Number of dwellings: ,_,�!
i Home garden/lawn irrigation, not to exceed one acre:
area irrigated ID sq. ft. B acre
0 Domestic animal watering — (non-commercial)
❑ C. Livestock watering (on farm/ranch/range/pasture)
7. Well Data (proposed)
Maximum pumping rate
gpm
Annual amount to tie withdrawn
acre-feet
1r;P7 3—A
Designated Basin Determination #
Water Court case #
Well name or if
Total depth )
feet
Aquiferu
8. Water Supplier
Is this parcel within boundaries of a water service area?I❑ YE5CI NO
If yes, provide name of supplier.
9. Type Of Sewage System
4. Location Of Proposed Well (Important! See Instructions)
tiUi
Vii,,� b0 114 of the 1/4
Townhip
Nora
D
Range E or W
Principainridian
(40
Distance of well from section lines (section lines are typically not property lines)
1 Fi. from ON'S p6Q Ft. from 0 E W
For replacement wells only — distance and direction from old well to new well
feet
Well location address (Include City. State, Tap) ❑ Check if well address is same as in Item 1
Direction
15oaS4j C,R- $I
Septic tank / absorption leach field
CICentral system: District name:
❑ Vault: Location sewage to be hauled to:
❑ Other (explain)
10. Proposed Well Driller License #(optional):
11. Sign or Enter Name of Applicants) or Authorized Agent
The making of false statements herein constitutes perjury in the second
degree, which is punishable as a Bass 1 misdemeanor pursuant to C,R,S.
24-4-104 (13Xa). 1 have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
Sign or enter name(s) of person
(s
.) submitting application
r {N iAIMJG��
Optional: GPS well location information in Ufor
mat foat GPS unit settings are as follows:
For
mat must be UN
❑ Zone 12 OD Zone 13
Units must be Meters
Datum must be NADB3
Unit must be set to true north
Was GPS unit chedhad for above? ❑ YES
Easting:
Northing:
Remember to set Datum to NAD83
5. Parcel•On Which Well Will Be Located
(You must attach a current deed for the subject parcel)
A. You mutt check and corn
O Subdivision: Name
one of the following:
Block Filing/Unit
County exemption (attach copy of county approval & survey)
Name Lot #
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
& bounds description recorded prior to June 1, 1972, and current deed
O Mining claim (attach copy of deed or survey) Name/#:
O Square 40 acre parcel as described in Item 4
❑ Parcel of 35 or more acres (attach metes & bounds description or survey)
❑ Other: (attach metes & bounds description or survey)
Date (mmtddlyyyy}
10.-1143
If signing pnntteAme and lide
7 ctactnr C C4F14 i tk) f'CthI .�y
Office Use Only
USGS map name
DWR map no.
Surface elev
B, # of acres in parcel
C. Are you the owner of this parcel?
cif YES Il NO
D. Will this be the only well on this parcel? p YESI11 NO (if no — list other wells)
E State Parcel ID# (ophonal)
51.j 5tJ per Receipt area only
'bi3+tncr�
'U
1745
AQUAMAP
WE
WR
CWCB
TOPO
24—
Trinsactlon #.
D
Transactors Total.
CHECK*1181
t)1
ON
3662411
.100 00
3100 Oft
WD BA MD
-I3 - czli
e
A- #f /340Th4
op col 5 • )3Ga r s
Q R. Na I-{-41444.- a-
n.r.ad tc hL e _ 0 - a nd
e Q� 0.14,a -G ;. Si 342731
to ek.. t#u0 R toga u"prn
k ba d w0 114-0
t
�iYR]•5•Rev..1b
Application must
be complete where
applicable. Type or
print In BLACK
INK. No overstrikes
or erasures unless
initialed.
Best Copy Available
COLORADO DIVISION OF WATER RESOURCES
818 Centennial Bldg., 1313 Sherman St., Denver, Calorsdo 80�ECEItt1ED
PERMIT APPLICATION FORMRE OCT 28 1985
( X) A PERMIT TO USE GROUND WATEINI\J 1.2 18115 WATER RESOD
los
K ) A PERMIT TO CONSTRUCT A WELL
FOR: ( Al A PERMIT TO INSTALL. A PUMP 8i0DUM= SAfE`ENQIt4ff
-MOM
RX)REPLACEMENT FOR NO. +h
( I OTHER
WATER COURT CASE NO.
CI) APPLICANT - mailing address
NAME Edwin C. Pirnie
STREET P. O. Box 40
CITY Briggadale Co 80611
{State} alp)
TELEPHONE NO. 656 3525
(2) LOCATION OF PROPOSED WELL
County We 1 d
NW k of the SW w, Section 14
Twp. 8 N Rng. 62
,
sE.+N1
6 P.M.
(3) WATER USE AND WELL DATA
Proposed maximum pumping rate (gprn) 15
Average annual amount of ground water
to be appropriated (acre-feet) :
Number of acres to be irrigated; None
Proposed total depth lfeet) : 450 ft
Aquifer ground water is to be obtained from:
Shale
1
Owner's well designation
Cs_ROUNO WATER TO BE USED FOR:
I ) HOUSEHOLD USE ONLY
(KX DOMESTIC CO
ON LIVESTOCK (21
( ) COMMERCIAL (4)
- no irrigation (0)
I ) INDUSTRIAL (5)
( ) IRRIGATION (6)
( ) MUNICIPAL (@)
[ ) OTHER (9)
DETAIL THE USE ON BACK IN (11)
(4) DRILLER
Name
Street
city Sterlin
Stewart Drilling Co
C
1.r
(State)
522 1454
Telephone No Lic, No. 66
FO.R OFFICE
49
Receipt No.
SE ONLY; DO NOT WRITE IN THIS COLUMN
37 / 10111
Basin _ Dist.
CONDITIONS OF APPROVAL
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.
,'APPROVED PURUSANT TO C.R.S. a00.002
J(S) (e) FOR THE RELOCATION OF F.KLSTEN WELL
PERMIT NO. W 1362'B TEE EXISTING
WELL MUST BE PLUGGED AND ABANDONED ACCORD-
ING TO THE RULES AND REGULATIONS FOR WATER
WELL AND PUMP INSTALLATION CONTRACTORS
WITHIN NINETY (90) DAYS OF COMPLETION OF
THE NEW WELL. THE ENCLOSED •AFFIDAVIT FORM
MUST BE COMPLETED AND SUBS AFFIRMING
THAT THE OW WELL WAS PLUGGED AND ABANDONED.
l�USE Of GROUNDWATER FROST MS *ELL IS UN.
TIED TO ORDI
PURPOSES INSIDE ONE
SINGLE FAMILY DWELLING. FIRE PROTON. THE
WATERING OF POULTRY, DOMESTIC WKS. AND
LIVESTOCK ON FARMS A%iO RANCI N o.- CS a5
APPLICATION APPROVED
PERMIT NUMBER 13.6 2- 73
DATE ISSUED
DEC 181985
EXPIRATION DATE DEC k 8 1987
COUNTY
Best Copy Available
(5) THE LOCATION OF THE PROPOSED WELL and the area on
which the water will be used must be indicated on the diagram below.
Use the CENTER SEC it'd"''0 acres) for the well location.
_ + — — — — -�
I
.LNORTN I
�4---- 1 MILE,3260 FEET
I
!
l
r
�
I
I
1
UTH SECTION LINE
f 4- - -I- 4. -+-
I I
—
(8) THE WELL MUST BE LOCATED BELOW
by distances from section lines,
1327 ft, from South sec line
(north or souTh)
270 ft. from West sec. line
oust or west)
LOT .BLOCK FILING
SUBDIVISION
(7) TRMCT QN WHICH WELL WILL
LOCATED Owner: Edwin C. Pirnie
No. of acres 320 . Will this On
the only well on this tract? Yes
-- -- 4— — —1—
The scale of the diagram is 2 inches = i mile
Each small square represents 40 acres.
(8) PROPOSED CASING PROGRAM
Plain Casing
—,5—.— in. from
0
ft. to 40Q ft.
in. from ft. to
Perforated casing
5 in. from 400 ft. to 4 5 0
in. from ft, to
ft.
t.
WATER EQUIVALENTS TABLE (Rounded Figuresi
An acre-foot covers 1 acre of Ilnd 1 foot deep
1 cubic foot per second Icf3) ... 449 gallons per minute (gpml
A family of 5 will require approximately 1 acre-foot of water per year.
1 acre -toot ... 43,560 cubic feet ... 315,900 gallons.
1,000 gpm pumped continuously for one day produces 4.42 acre-feet.
(9) FOR RE LACEMENT WELLS givedistance
and direction from old well and plans for plugging
it:
Offset the old well by
about 10 ft. or so to the east
ThP old wi'1l wi11 he plijggeli
aernrtiinq 1-n the ry1Ps_
(10) WHICH GROUND WATE W
Owner(lil: Edwin' C. Pirnie
Legal description: x �f
(11). CIETAILED `SC IPTf10Y of the of ground water: ill dd IOa in o� cep. o iisposal
oiYfseh use end am a wells nsu 'collets
system to be used.
No, of acres: 320
Domestic and livestock. The waste water from the house will
--, qo thraug a sepf is tank and I PPe-.h i i 1r►a
(12) OTHER WATER RIGFITS used on this land, including wells. Give Registration and Water Court Case Numbers.
Type or right
None
Used for (purpose)
Description of land on which used
(13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS
TRUE Ti T E BEST OF HIS KNO. EDGE.
SIGNATURE OF APPN..ICANT(S)
1st —
Use additional sheets of paper if more space is required.
_ft.
wJRe.77
Best Copy Available
TMIS FORM MUST BE SUBMITTED
WITHIN 40 DAYS OF COMPLETION
OF THE WORK DESCRIBED HERE-
ON. TYPE OR PRINT IN BLACK
INK.
WELL OWNER
ADDRESS
COLORADO DIVISION OF WATER RESOURCES
1313 Sherman Street - Room 818
Denver, Colorado 80203
liECEIVED
WELL COMPLETION AND PUMP INSTALLATION REPORT JAN 1.0 1986
PERMIT NUMBER 136273-A OVER
Edwin C. Pirnie
P. D. Box 40
Briggsdale, Co 80611
DATE COMPLETED Nov 4
WELL LOG
1985
From I To
Type and Color of Material
Water
Loc.
0 10
10 25
25 40
40 230
230 260
260 403
403 1423
Use a
Brule type clay
Sand
Shale ocare
Shale with rock & coal
streaks
Soft grey shale
Soft grey shale, sands
streaks
Soft grey shale
TOTAL DEPTH 423 f t.
dditional pages necessary to complete log.
Xx
xx
NW of the
T 8 N R. 62 W 6
.HOLE DIAMETER
_ .72./i& from to. 5& ft.
MOSS -Dow
SW %o 14
—6.-34-4n. from — ,Z.S$_ too-- ft.
in. from to ft.
DRILLING METHOD Rotary _
CASING RECORD: Plain Casing
Size _4 & kind
PVC
from _g ____ to
Size _.v & kind from _ to
Size & kind w from
Perforated Casing
Size 4 & kind PVC . from 265
to
P.M.
265
to423
Size & kind from to ft.
Size _ __ & kind __ _ _.... from to ft.
ft.
ft.
ft.
GROUTING RECORD
Material Cement
ft.
Intervals From 10 to 20 ft
Placement Method Mixed & poured
GRAVEL PACK: Size _ Burkahot
Interval
TEST DATA
Date Tested uov :4
198.5_
Static Water Level Prior to Test ft.
Type of Test Pump Bai IPr
Length of Test 3 hours
Sustained Yield (Metered) 15 GPM
265 ft.
Final Pumping Water Level
I
Best Copy Availc,ible
'PUMP INSTALLATION REPORT
Pump Make Re rk 1 Py
Type glihmcterlble
Powered by Electric HP 34
Pump Serial No. 1014G 17
Motor Serial No.
Date Installeo November 10, 1985
Pump Intake Depth 321 ft.
Remarks
WELL TEST OATA WITK PERMANENT PUMP
Date Tested November 10, 1985
Static Water Level Prior to Test 220 ft
Le^qth of Test _ 3 Hours.
Sustained yield (Metered) 15 GPM
Pumping Water Level 265 ft
Remarks _
TAL DEPTH
WATER
!�+ 1 TABLE
m
CONTRACTORS STATEMENT
The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or
pump installation described hereon; that he has read the statement made hereon; knows the content
thereof, and that the same is true of his own knowledge.
Signature
State of Colorado, County of Logan
Subscribed and sworn to betore me this 8 day of January
My Commission expires:
Notary Public F
May 2 .1983__.
License No. 6.6
FORM TO BE MADE OUT IN QUADRUPLICATE! WHITE FORM must be an original copy on both sides and signed.
WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Driller.
• Sc'
A
TYPE OR -
Pit INT IN LAC INK
COPY OF ACCEPTED
STATEMENT MAILED
ON REQUEST
COLORADO DIVISION OF
RECZ VED VED
WATER RES RICCS lu ";: ien�,
, 818 Centennial Bldg., 1313 Sherman St. it+13t Isiggha
Denver, Colorado 80203
STATE OF COLORADO
COUNTY OF
f SS
SWEeftilie
WEE RMIL
Esouers
STATEMENT OF BENEFICIAL USE OF GROUND WATER
Best Copy Available AMENDMENT OF EXISTING RECORD
LATE REGISTRATION
x
PERMIT NUMBER
THE AFFIANT(S) /
whose mailing
address is ..49/ EX DER 1YE
City
IS••r r1
136273
51x431
County
Tw.p
MP. 3 11984
IItV'• 'it: .�it.er
LOCATION OF WELL
�y ar the ' �� Soc ',err
. R.9
N 0. SI IF i• nr
being duly sworn upon oath, deposes and says t at he (they) s (ore) the owner(s) of the well described ereon,
447
lac ed as described above, of distances a > feet from the --section line andfeet horn the
~.4.1,,014. section line, water from this wel,l was first applied to a beneficial use for the purpose(s) described herein on the _____
lealt oe er7•1
P
,,.tea
day f
19 otipL7
/3t.41474.4 d‘te,re /801"
e maximum sustained pumping rate of the well is
isOP•• 0. •Dv..•7
the well Iti
1.7 gallons per minute, the pumping
rate claimed hereby is ./_ gallons per minute; the total depth of the well is 7.610 feet; the overage annual amount
of water to be diverted its
/1
Palma -57v c a ? /01
441lacres are irrigo�"and whit is i ustrat on " 'map on t rave - r •rm; mat r-^ • . co •feted in
compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with low; he
(they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge
acre-feet, for which claim is hereby made for
purpose(s), the legal description of the land on which the water from thrs well is usedis
c.+.s C /
O R/�ILs h. .' . ,wir: JPr' 0 .1. wf +
�
Signoture(sl
Subscribed and sworn
to before me on this
day of
My Commission expires: S !�+
MPLETE REVERSE SIDE OF THIS FORM)
, 19 Re...
ft
ACCEPTED FOR FILING BY THE STATE ENG NEER OF COLORADO
PURSUANT TO THE FOLLOWING CONDITIONS:
ACCEPTED PURSUANT TO C.R.S.. : TriZ002
(6) FOR USE AiS DESRI>3ED IN Ct
3?42402 (1)(.., __). 7.2
JUL 201984 „L/C./
DaTE
S'nTE F'J,NEFR
Assistant
?-2
Cowl Cote No
Pr 'Dr
FOR OFFICE USE ONLY
MO Day - Yr
I
62
`,y
Sec % /. . .._ /.
Well IUse 3
Date 1 _ ga n Mon o�•.
Best Copy Availabfe
ifj.
Weil drilled by 'la ,.t7 Latatstegeg, Lic. No.
Permol rt
Pump Fp%tolled by
Meter Serial No. ❑ Flaw Meter Date Installed
Owner of land on which
water is being used
Lic. No.
THE LOCATION OF THE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS THE
AREA ON WHICH THE WATER IS USED MUST BE SHADED OR CROSS -HATCHED ON THE DIAGRAM BELOW.
NORTH
This diagram represents nine (9) sections. Use the CENTER SQUARE
(one section) to indicate the location of the well, if possible.
I
+ —
1
+ —
I
+ —
I
+ _
I
.I
I
+
I
I
+ —
I
+ —
I
I
+ —
NORTH SECTION
I
+ —
LINE:
I
+ .,T
I
+
`
�- V `-
A
WEST SEC
+ —
6
+
---
‘.1
Syr
*",3
-r -iii _
CI)115:11 V°
3N11 NOI
p
1 + -.-
w
I
+
I
't°'
+
+
SOUTH SECTION
T +
LlhfE
— +
+
T1 -E
+ .r
SCALE OF THE
+
DIAGRAM IS
— +
---1 Mile--
TWO INCHES EQUALS
— + __._
ONE -MILE
+
l
— +
WATER EQUIVALENTS TABLE (Rounded Figures)
An acre-foot covers 1 acre of land 1 foot deep.
1 cubic foot per second (cis) . . . 449 gal Ions per minute (gpm).
1 acre-foot . .. 43,560 cubic feet .. . 325,900 gallons.
1,000 gpm pumped continuously for one day produces 4.42 acre-feet.
100 gpm pumped continuously for one year produces 160 acre-feet
(WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER
PINK COPY WILL BE RETURNED TO OWNER) •
0
z
Best Copy Available
G
VERBAL AND MARKS INFORMAT'!ON SHEET
!)
Initial Permit NO. 436.34Z,
' Date verbal pro :
r�inal Fe:mia No.
REQUEST FOR VERBAL APPROVAL
ate e . 1
.� L�
Driller
.�uT
Location �.�
County
Address:
..
i Vic. :To. Fh
Q' }
.SEC E,, ,/
• n
New Q
ten.
w._C
Permit No.
.Phone
Alt. Pt. DivL T.R.C--71
Distances from Sec. Lines
J
Arproved No
s
P'17-9"4 D�th:
Casing:Plain.
EY :
7 Eato of Constzvctron
Perf
�
ID _ County —:::::.7.
Surd vl,sion
rrr
Baca �a,,aa,a..a_a aaa
M,iy►aay �..i .-Y . .sa- c7iay
Date
Initial
Contac,, and
ITii�:ber
R E H S
r
vilea
. .A
%� 4.--�
, �JYI�Gtr 't! F„,„ _
d ..
7"9-44-
.
•� ' A 1 r/ �1'/
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lir
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I
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sonnet
COLORADO DIVISION OF WATER RESOURCES
1313 SHERMAN ST. ROOM 818
DENVER, COLORADO 80203
PHONE: 866-3587
APPLICANT (C.} ATTORNEY ( )
Your application to record an existing well has been reviewed. It is being returned
to you for additional Information as indicated below.
( In order to accept an application to record an existing well, there must be a field
inspection by the Division of Water Resources personnel to verify the existence and
use of the welt. To arrange for a field inspection of the well, please contact:
DIVISION ENGINEER WATER COMMISSIONER
The existence and use of the welt must be confirmed by Division of Water Resources Per-
in writing and the application returned to this office for further action.
(f OTHER:
-old
7
0
()
Best Copy Available
CfORADO DIVISION OF WATER RESOURCES
•
818 Centennial Bldg., 1313 Sherman St.,
Derver,•Colorado 802O3
APPLICANT ()
RE: Well Permit Application for an exempt well.
FROM: Robert 8o sen
DATE: /
PHONE: (3O3)839-3587
9''
WELL DRILLER ( ) ATTORNEY ( )
We are sorry for the delay and inconvenience, but your application
for a well permit is being returned for the reason(s) indicated below.
The additional data and corrections, which we are requesting will aid us
in evaluating your application. Prompt completion or correction of ALL
items checked in RED and the immediate return of the application to this
office will expedite its processing. Thank you for your attention.
PLEASE INITIAL ALL CHANGES. PLEASE TYPE OR PRINT IN BLACK INK.
Statute requires a $ fee for this type of application. Please
return the application with required fee.
The well location must be designated by the county and the L/4 of
1/4, Section, Township, Range and P.M. (Item 2.)
Distances from section lines must be shown. (Item 6)
The 1/4 of 1/4 section (It:) does not agree with distances from
section lines Jighiel
For a DOMESTIC WELL no more
be irrigated (Item 3).
For a HOUSEHOLD USE ONLY WELL, no irrigation of lawns or gardens can
be permitted (Items 3 and 11).
Please indicate the proposed total depth (Item 3) .
If this well is to be used for Household Purposes Only, with no lawn
or garden watering, please indicate on the application under "Ground
Water to be Used Fors" (Item 3.) Do not indicate HOUSEHOLD USE ONLY
and DOMESTIC as they are'different.
The proposed casing program must be completed (Item 8).
The existing well must be plugged and abandoned according to rules and
regulations. Please include the distance and direction from the old
well (Item 9).
If this well is to be the only well on 35 acres or more, please
describe the acreage on the back of the application under LEGAL
DESCRIPTION in Item 10.
Please indicate the specific use intended for the water, and the type
of disposal system to be used, or a copy of the disposal permit (Item
Please complete Item(s) where checked in red.
Signature of applicant is required on application (Item 13).
Please provide a copy of a tax receipt, a surveyor's plat, or a warr."".t1
deed to show ownership of the property described in Item 10..This sho•.1:c
give the date when the land was subdivided.
than one
Other: A -'O 'Y'�D /y / /+/ 1 d E. ,s4''rte!
(1) acre of lawn or gardens can
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DEPARTMENT OF NATURAL RESOURCES
DIVISION OF WATER RESOURCES
December 10, 2013
Duangchai Washburn
110 Oak Ave.
Eaton, CO 80615
RE: Receipt No. 3662411
John W, Htckenlooper
Governor
Mike King
Executive Director
Dick Wolfe, P.E.
Director/State Engineer
The application for a permit to register an existing well is being returned for the reason(s) listed below.
If you have any questions, I can be reached @ 303-866-3581.
• After further review of our records, it appears that your parcel has an existing well that
was permitted under permit no. 136273-A. This is a valid well permit See enclosed
well permit copies. Per our phone call on 12-9-2013 you said you are in the process of a
recorded exemption for a 10 acre parcel that you are exempting off of the 320 acres that
you own. When that is completed send back your well permit application and change the
acres and the use to "Household" use only. We would then cancel well permit no.
136273-A and issue you a new well permit. The original permit no. 136273 was supposed
to be plugged and abandoned according to the replacement permit no. 136273-A.
Please submit an abandonment report to us showing that the old well was plugged. You
might to have a driller help you to do that. That form can be down loaded from our website
@ http://www.water.state.co.us.
Please be advised that the aforementioned criteria must be addressed and received by
this office by February 10, 2014 to retain active status of the ground water well permit
application. Information submitted after that date will require a new ground water well
permit application and will be assessed the appropriate fee.
Thank you,
4 .2.
Arlene a Boone
Water Resource Specialist
Office of the State Engineer
1313 Sherman Street, Suite 818 • Denver, CO 80203 • Phone: 303-866-358I • Fax: 303-866-3589
www.water.state.co.us
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