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DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 821, DENVER, CO 80203
Main: (303) 866-3581 dwrpennitsonlineffstate.co.us
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
Michael and Mary Sue Krier
Mailing address
6001 W 21ST Street
City I State --- Zip code
Greeley CO -1 Zip
Telephone # (area code & number) � E-mail (online filing required)
970-539-656
VIIII,G 'JOG VIIllr
I-orm Civv-4o (U1/LU13)
2. Type Of Application (check applicable boxes)
® Construct new well El Use existing well
❑ Replace existing well ❑ Change or increase use
❑ Change source (aquifer) ❑ Reapplication (expired permit)
❑ COGCC Well ❑ Other:
3. Refer To (if applicable)
Welt permit * Water Court case S
Designated Basin Determination #
Well name or #
6. Use Of Well (check applicable boxes)
Attach a detailed description of uses applied for.
❑ Industrial
❑ Municipal
❑ Irrigation
p Commercial
• Dewatering System
❑ Geothermal (production or reinjection
❑ Other (describe):
7. Well Data (proposed)
-_-_.._......
Maximum pumping rate Annual amount to be withdrawn
15 gpm 1/3
Total depth Aquifer
125
feet ;All Unnamed
acre-feet
4. Location Of Proposed Well
County
Weld SW 114 of the SE 1:4
Section
Township N or 5 I Range E p w Principal MeeridiarUa n
25 j9 lit —I 61 ❑� ;6TH
_.y—— - ---- ...........
Distance of well from section fines (section lines are typically not property lines)
Et. from i N ! S Ft. rrarrUlE ❑W
For replacement wells only - distance and direction from old well to new well - -
feet direction
Well location address (include State ',tip) address
--- """ent
l y p) � Check it well addresis same as rn item 1
Optional: GPS well location information in UTM format You must check GPS unit for
required settings as follows'
Format must be UTM
I.—{ Zone 12 eta.] Zone 13
Units must be Meters
Datum must be NAD83
Unit must be set la true north
Was GPS unit checked for above? ❑ YES
Easting 571542
Northing 4507243
Remember to set Datum to NAD83
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).
B. # of acres rnparcel c. Owner
20
Michael & Mary Sue Krier
D. Edit this be the only weli on this parcel? El YES❑ NO (it no list other wells)
E. State Parcel 1D# loptional)
8. Land On Which Ground Water Will Be Used
Legal Description of Land (may be provided as an attachment) -
Of used (or crop Irrigation, attach a scaled map that shows irrigated area )
A. if Acres i B. Owner
C. List any other wells or water rights used on this land
9. Proposed Well Driller License #(optio nal): 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 t 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 or enter name(s) of person(s) 5ubmdUng application Date (mmlddlyyyy)
l
"L�t,(�a �.. '� �. )Jf. , ,
It signing print name and title -- _ - -
\ (.- (`L Ci: ( v i - y. .
Office Use Only
USGS map name
AOUAMAP
WE
wu
CWCB
TOP()
MYLAR
SOS
GWR reap no. ! Surface elan
Receipt area only
DIV WD BA MD
COLORADO DIVISION OF WATER RESOURCES GWS-45 GENINST (07/2013)
DEPARTMENT OF NATURAL RESOURCES
GENERAL PURPOSE WELL PERMIT APPLICATION INSTRUCTIONS
Applications must be computer generated on-line, typewritten or printed in BLACK or BLUE INK. ALL ITEMS in the
application must be completed. Incomplete applications may be returned to the applicant for more information.
Applications are evaluated in chronological order. Please allow approximately six weeks for processing. This form
may be reproduced by photocopying or computer generation. Reproductions must retain margins and print quality of the
original form. If filing online see online filing instructions! You may also save, print, scan and email the completed form to:
dwrpermitsonlinestate.co.us For further information please visit www.water.stale.co.us
FEES: This application must be submitted with a $100 filing fee. Acceptable forms of payment are check or money
order, payable to the Colorado Division of Water Resources. Visa, MasterCard or Discover are accepted by phone through
our Records Section at 303.866.3581. Fees are nonrefundable.
USES: This form (GWS-45) is to be used to apply for commercial, industrial, municipal, irrigation, feed lot,
geothermal (see Geothermal Rules for fee requirements), recovery wells, and other uses not otherwise noted in the
following list:
RESIDENTIAL use wells — Use of form GWS-44 is required
LIVESTOCK watering on a farm, ranch, range or pasture (not feedlots) — Use form GWS-44
MONITORING/OBSERVATION wells — Use form GWS-46
GRAVEL PITS — Use form GWS-27
REGISTRATION of an existing well — Use form GWS-12 (must have been in use prior to May 8, 1972)
GEOEXCHANGE SYSTEM LOOP FIELDS — Use form GWS-72
REPLACEMENTS OF WELLS FOR THE ABOVE USES
ITEM INSTRUCTIONS: (numbers correspond with those on the front of this form)
1. The applicant is the entity for whom the permit is to be issued. Provide the applicant name and the mailing address where all correspondence will be
sent.
2. Check all boxes that apply.
3. Complete all boxes that apply. If the permit is to be issued pursuant to a water court decree or a Designated Basin determination of water right, the
case number or determination number must be indicated. If applying to replace or change the use of an existing well, the permit number of the existing
well must be indicated.
4. The county, 1% of the 'Y4 section designation, section #, township, range, principal meridian, and distances from section lines for the proposed well must
be provided. (An option to providing distances from section lines and the 14 of the 1/4 section designation is to provide an accurate GPS location in UTM
format. The required GPS unit settings must be as indicated on this form.) Colorado contains two (2) UTM zones. Zone 13 covers most of Colorado.
The boundary between Zone 12 and Zone 13 is the 108`" Meridian (longitude). West of the 108h Meridian is UTM Zone 12 and east of the 108'"
Meridian is UTM Zone 13. The 108`" Meridian is approximately 57 miles east of the Colorado -Utah state line. On most GPS units, the UTM zone is
given as part of the Easting measurement, e.g. 12T0123456. Check the appropriate box for the zone. Provide the property address of the well location
if one exists. If it is the same as the mailing address, check the box next to the well location address.
5. Please attach a current deed for the subject parcel. Complete all boxes and provide a complete legal description of the parcel of land on which the
well will be located. If filing online please see online filing instructions for how to submit deed and or legal description attachments.
6. Check all boxes that apply and attach a detailed description of the uses applied for.
7. Complete all boxes.
8. Complete all boxes and provide a legal description of the land areas on which ground water from the proposed well will be used. If agricultural irrigation
is a proposed use, provide a map of the land area with proposed irrigated areas accurately drawn, including section numbers and section lines. A list of
all other wells or water rights used on the described land must be provided.
9. The well must be constructed by a Colorado licensed well driller, an authorized individual in accordance with the Water Well Construction Rules, 2 CCR
402-2, or under the "private driller" provision as defined in CRS 37-91-102(12). A listing of licensed well drillers/pump installers is available at:
http://waterstataco.usiqlounclvvater/B0E/Paqes/LicenseciContractors.aspx
10. The individual signing the application or entering their name and title must be the applicant or an officer of the corporation/company/agency identified as the
applicant or their attorney. An authorized agent may also sign the application, if a letter signed by the applicant or their attorney is submitted with the
application authorizing that agent to sign or enter their name on the applicant's behalf. If you filled the form out on-line you may save or print, sign, scan and
email the form to the Division of Water Resources. Payment must be received via phone, fax or mail prior to processing the application.
IF YOU HAVE ANY QUESTIONS regarding any item on the application form, please call the Division of Water Resources Ground Water Information Desk (303-
866-3587), or the nearest Division of Water Resources Field Office located in Greeley (970-352-8712), Pueblo (719-542-3368), Alamosa (719-589-6683),
Montrose (970-249-6622), Glenwood Springs (970-945-5665), Steamboat Springs (970-879-0272), or Durango (970-247-1845), or refer to our web site at
htto.//www water.state.co.us for general information, additional forms, and access to state rules or statutes.
WERNSMAN
ENGINEERING AND
LAND
DEVELOPMENT llc
October 22, 2018
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 #8 Site
To whom it may concern.
The septic system for Expedition Water Solutions on Parcel # 046525000003
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.
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