HomeMy WebLinkAbout20193428.tiffWERNSMAN
ENGINEERING AND
LAND
DEVELOPMENT 11c
February 25,2019
Weld County Health Department
1555 N 17th Ave
Greeley, CO 80631
Eric Wernsman
16493 Essex Rd S
Platteville CO 80651
RE: Septic System for Expedition Water Solutions EWS #11 Site
To whom it may concern,
The septic system for Expedition Water Solutions on Parcel # 147534200009 will be
designed if the USR is approved.
If you have any further questions or comments regarding this matter,
please contact this office.
Sincerely,
Eric Wernsman P.E.
DocuSign Envelope ID: BEFB9FFB-4550-40F1-B758-5ADF39599310
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 821, DENVER, CO 80203
Main: (303) 86B-3581
GENERAL PURPOSE
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be computer generated, typed or in black or blue ink.
1. Applicant Information
Name of applicant
PATRICK & JULIE SIMONS
Mailing address
15521 ALMSTEAD STREET
City Seale Zip code
HUDSON CO 80642
Telephone fi (area code & number) E-mail (online filing required)
970-539-2656 ejwerns25@gmail.com
Office Use Only
Form GWS-45 (07/2013)
6. Use Of Well (check applicable boxes )
Attach a detailed description of uses applied for.
El Industrial
❑ Municipal
❑ Irrigation
■❑ Commercial
❑ Dewatering System
❑ Geothermal (production or reinjection
❑ Other (describe):
2. Type Of Application (check applicable boxes)
■❑ Construct new well
El Replace existing well
❑ Change source (aquifer)
El COGCC Well
❑ Use existing well
El Change or increase use
❑ Reapplication (expired permit)
❑ Other:
7. Well Data (proposed)
Maxirnuln pumping rate
15
Told depth
400
Annual amount to be withdrawn
gpm 1/3
Aquifer
feet ALL UNNAMED
acre-feet
3. Refer To (if applicable)
well permit
Designated Basin Determination in
Water Court case. :f
Well name or fr
4. Location Of Proposed Well
County
WELD NW 1/4 of the NW 1,4
Section Townettip Nor S Range E or W Principal Meridian
34 1 XI I I 64 ❑ ❑ 6TH
Distance of well from section brine {section lines ore typically not property lines)
342 Fl. trom l)f N I S 124 Ft. fromnE 0W
For replacement wells only — distance and direction from old well to new well
feet direction
Well location address (Include City. Stale. Zip) ❑ Check if well address is same as in Item 1
Optional: GPS well location information in UTM format You must check GPS unit for
required settings as follows:
Format must be UTM
Zone 12 or1;111 Zone 13
Units must be Meters
Datum must he NADB3
Unit must be set to We north
Was GPS unit checked for above? ❑ YES
Easting 538753
Northing 4429428
Remember to set Datum to NAD83
8. Land On Which Ground Water Will Be Used
Legal Description of Land (may be provided es art atlachmenty
NW1/4NW1/4 OF SECTION 34, TOWNSHIP 1N, RANGE 64V
(If used for crop irrigation, attach a scaled map That shows irrigated area.)
A. # Acres B. Owner
C. List any other wells or water rights used on this land:
9. Proposed Well Driller License #(optional): 1461
10. Sign or Entered Name Of Applicant(s) Or Authorized Agent
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.
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
6b&Offirofi'23E0) of person(s) su t4e eppgig'ir a by: Oats (mnvddfyyyy}
Paltdc54,ALs A& Q. 51.0I/LS 3/12/2019
ggNEIELTpt7EWe®@qitille BAFE2D7BAB5D487... --
Patrick G. Simons Julie A. Simons
5. Parcel On Which Well Will Be Located
(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A Legal Description (may be provided as an attachment):
NW1/40FNW1/4 OF SECTION 34, TOWNSHIP 1N, RANGE 6,
of acres in parcel
C. Owner
20 PATRICK & JULIE SIMONS
D. Will this he the only well on this parcel? X❑ YES NO (it no list other wells]
E. Stale Parcel Oft (oplional):
147534200O09
Office Use Only
USGS map lucre
AUUAMAP
WE
wk
MGR
TOPO
F.IYLAR
SB5
DW R map no. Surface elev,
Receipt area only
DIV WD BA MD
DocuSign Envelope ID: BEFB9FFB-4550-40F1-B758-5ADF39599310
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., STE 821, DENVER, CO 80203
main: (303) 866-3581 thii::_, :, t_: ;_-etc; �.,. ! I..
Form GWS-57 (10/2013)
Application
Applicant's
Receipt No.
Name:
COMMERCIAL DRINKING AND SANITARY WELL WORKSHEET
Review instructions on reverse side prior to completing form. The form must be completed in black or blue ink or typed.
1. Name and Type of Business: PATRICK & JULIE SIMONS - EXPEDITION WATER SOLUTIONS
2. Is this application for a new well?
❑ Yes
❑ No If no, is this application for a change of use for an existing well?
• Yes Permit Number of well (if applicable)
❑ No For wells used for drinking and
sanitary purposes prior to May 8, 1972, a field inspection of the well to
verify historical uses may be required. See form
r:w','t;- i 7 I 1is::.ir I or L::i;i:::,_i ,,r,/t.,!I and
form C''.''3.-i2i', 3tute:»cnt
tr.. I-,i3loric;tl t1 c for
further information.
3. Is the parcel the well is located on (or will be located on) within the boundaries of a water service area (water district,
municipality, water company, etc.) or is water available front another source (such as a well)?
■ Yes If yes, indicate what this other source is
❑ No
(name of water districtsupplier, or well permit number)
4. Proposed type of disposal system to be used:
❑ Septic tank / absorption leach field
❑ Central System (district name;)
• Vault (location sewage hauled
to:)
❑ Other (attach copy of engineering
design)
5. Water Demand Calculations (for average factors for water demand see below)
Employees
Number of
X
Number of Gallons
X
Number of Days Employee
=
Gallons per Year
Employees
per Employee per Day
Works per Year
15
X
15
X
355
=
A
Customers
Number of
X
Number of Gallons
X
Number of Days Business
=
Gallons per Year
Customers per Day
per Customer
is Open per Year
10
X
5
X
365
=
B
Other Uses (Note: No uses outside of the building would be permitted for this type of well.)
Type of Use
X
Gallons per Use per Day
X
Days per Year
=
Gallons per Year
X
X
=
C
Total amount
of water required:
=
Gallons per Year
(A + B + C)
100375
For wells used for commercial drinking and sanitary purposes
on or after May
8, 1972, the total water demand cannot exceed
108,600 gallons (1/3 of an acre-foot) per year.
For wells used for commercial drinking and sanitary purposes
prior to May
8, 1972, the total water demand cannot exceed 325,900
gallons (1 acre-foot) per year.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices —15 gallons/person/day
Food Service Establishments (with toilet and kitchen wastes)— 10 gallons/patron/day
Churches (does not include food service) — 5 gallons/seat/day
Overnight Lodging — 50 gallons/customer/day
On -Site Proprietor of Overnight Lodging (i.e. on -site owner of a Bed & Breakfast) — 80 gallons/person/day
Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject.
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