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• WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1 1S55 NORTH 17TH AVENUE
GREELEY,CO 80631
PHONE(970)304-6415 FAX(970)304-6411
Dialed
Permit#: SP-0300476 - Sec/Twn/Rng:27-11-67 Status: ENG-HOLD
Owner: THOMPSON WILLIAM S Applied: 12/05/200.1
Applicant: ANDREWS LARRY Issued: -11-/(19-O ,1
Permit Type: RNEW Carnrnercial,R-Rcsidrntiai+NEW,REPair,VauLT Finaled: ej-oft'
Parcel#: 0201-27-- -
Location: 9348 McGUIRE AVE
Legal Descri lion•
Installer: }f 'r�J . Pte' c Cam, r�tl i
Description: MODULAR HOME
Commercial: N Residential:Y Acres: 0.51
#of Persons: 2 Basement Plumbing: N
#ofBedrooms: 3 Bathrooms-Full: 2 3/4: 0 . 1/2: 0
Water Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit#: 254064
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Percolation Rate: 36 Limiting Zone: 0 ft 0 in Description: SAND/COBBLES
%Ground Slope: 0 Dir: Soil Suitable: (Y/N) N
Engineer Design Required: (Y/N) Y In 100 Year Flood Plain: (Y/N) N
minimum Installation Chambers
Septic Tank: 1000 gallons Absorption Trench: 0 square feet
or Absorption Bed: 1392 square feet
Actual Installation
Septic Tank: t000 !gallons Absorption Trench: square feet
Absorption Bed: i to$5 square feet ‘y.
Design Type: 4.4.
NOTICE
The issuance of this permit does not imply compliance with other state,county or local regulatory or building requirements,nor shall it
act to certify that the subject system will operate in compliance with applicable state,county and local regulations adopted persuant to
Article 10,Title 25,CRS as amended,except for the purpose of establishing final approval of installed system for issuance of a local
occupancy permit persuani to CRS 1973 25-10-111(2).
This permit is pan I_aastarabte,a.nd_non_refund aWe. The Weld County Department of Public Health and Environment reserves the
right to impose additional term and conditions required to meet our regulations on a continuing basis. Final permit approval was •
contingent upon the final inspection of the completed system by the Weld County Department of Public Health and Environment.
x . .a
Env rontn tal Health Specialist Date
Form:S FINAL
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 1299
WELL PERMIT NUMBER 254064 - -
DIV. 1 WD 1 DES. BASIN MD
APPLICANT
Lot: 4 Block: 21 Filing: Subdiv:CARR TOWN OF
APPROVED WELL LOCATION
WELD COUNTY
SE 1/4 NW 1/4 Section 27
WILLIAM THOMPSON Township 11 N Range 67 W Sixth P.M.
P O BOX 270015 DISTANCES FROM SECTION LINES
FT COLLINS, CO 80527- 2516 Ft. from North Section Line
1872 Ft. from West Section Line
(970)204-4929 UTM COORDINATES
PERMIT TO CONSTRUCT A WELL Northing: Easting:
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 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)(b)(I1)(A)as the only well on a residential site of 0.50 acre(s)described as lots
4-6, block 21,Town of Carr,Weld County.
4) The use of ground water from this well is limited to ordinary household purposes inside one single family dwelling. The
ground water shall not be used for irrigation or other purposes.
5) The maximum pumping rate of this well shall not exceed 15 GPM.
6) The return flow from the use of this well must be through an individual waste water disposal system of the
non-evaporative type where the water is returned to the same stream system in which the well is located.
7) This well shall be constructed not more than 200 feet from the location specified on this permit. ,\R ////a 103
APPROVED .16 o
SKt3 `
State Engineer By
,Receipt No.0517389 DATE ISSUED 11-12-2003 EXPIRATION DATE 11-12-2005
Form STATE OF COLORADO For Office Use Only
No_ OFFICE OF THE STATE ENGINEER Rectipla Yk a S)73 81
GWS-1 1 818 Centennial Bldg., 1313 Sherman St,Denver,CO 80203
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6/2006 Phone—Info:(303)866-3587 Main:(303)866-3581 •
Fax_(303)866-3589_ hftp;Nwww_waterstate.ca.us I Rs'�'+ r
CHANGE IN OWNERSHIPIADDRESS ;.'��
_CORRECTION OF THE WELL LOCATION MAY 15 24y
Review instructions on the reverse side prior to completing the form-
wArso Name, address and phone of theperson claiming ownership of the wefl3 srs�rryA . .; ''
�a r:rarrr
Mailing Address:
City,St.Zip:
Phone LVA 'f7 TIJ
This form is fired by the named individualfentity claiming that they are the owner of the well permitted as referenced above,
This filing is made pursuant to C.R.S.37-90-143.
WELL LOCATION: Well Permit Number: 254064 Receipt Number
County Weld.
- owner's Well Designation(optional)
906 .2-9424
(Address)
(City) Pate) (Zip)
S)E£ 1I4 of the -NW 1/4,Sec. 27 .Twp. 11 El N.or DS., Range 67 0 E.or El W., 6th P.M.
Distance from Section Lines: 2516 ft Ft From®N.or 0 S_, 1872 Ft From O E.or IN W.Line.
Subdivision Name _ Lot 4-6 , Block 21 , F,ling/Unit Carr CO
The above listed owner(s)say(s)that he, she(they)own the well described herein. The existing record is being amended for
the following reasons:
Change In name of owner O Change in mailing address O Correction of location for exempt wells permitted prior to May
, 1 72 and non-exempt wells permitted before May 17, 1965.
Please see the reverse side for further informstinn ronar,linr....,..a..►:...,..cm_ „,,.ram.,eal
I(we)claim and say that I(we)(are)the owner(s)of the well described above, know the contents of the statements made
herein.and state that the are true tom our knowled e.
S' ture(s)M�er Please print the Signer's Name&Title Date
Allen Clark
Elsie Clark 5-23-07
It is the responsibility of the new owner of this well to complete and sign the form. Signatures of agents are acceptable if an
on final letter of ayeny s red by the owner is attached to the form u n its recei #.
For Office Use Only
ACCgpTED AS A CRANGE OF OWNBASUJP
niwrv..prnrrrr•v rrrmmirma1
'61;140/1034.-
t'ol i?State Engineer By t(O1
Date
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a COLORADO DIVISOR OF WATER RESOURCES _
DEIa/ TMEIiIT OF NATURAL RESOURCES OfOce Use Only Form GWS44(312003)
1313 SHERMAN ST.,RAN 818,DENVER,CO 80203
phone-Info:(303)888.3597 Mail:(303)868-3581
fait(343)863-3589 http:lfwwwwatarsiate.no.E�s ff
RESIDENTIALvislock �'-L�l " 2�'J3
waterIng
Water Weil Permit Application %.
Review IfiainiCtiOnS nn reverse side prior to completing form.The form must be completed in black Ink.
,'1,Li.J
oP[Foppturt
( Inform -� - 6.Use Of WWII(c# ck applicable boxes
/(�J '� See icbons to detemirn9 Metal fu-uML-.h boxes)._
ipja ---
V 1 f f —~�
21 A O{{ h a use 'IRA 6-• ...seu.aL.,t-.--y s.,.ZJn.-4
'
eay Q Box 70015 ,
ma code Number
B.Ordinary household use in i b 3 single-f ity dwelings:CPr Call•.IS . �- - 7
Ner of dwellings:-reieynoreue ❑Horne gerderviavwrr irrigation,not lo mead one ape:
( 1 ) . - area Irrigated_ - 0 sq.I❑acre
2. Type Of Application(check applicable a boxes) - ❑Darnesue animal w�
�Construct new well �, �-{r►omm�omrremrrai)
❑Constru tnayexisting wail ❑klse unci aing emit Ca C_uve5tpdt watering(on fam11ranc lrange� )
❑Change source ❑Changeorincrease use .
❑Chang (aquifer) ❑Reappihcwian(expired permit) 7.Well Data(proposed)
Maxiwmra pump tip I ! Metal ome�t to�eedieboun
3. Refer To(if applicable) �sp /
Wall pe rms g " 1Kxe+m omet e Taw depth 15 m r7Lrtta 1! aura-feel
UD fast 4Alie4Aliz •t1+ !le
a.• .-- .:uo�n*ozrun Wdrremecrr 0.Wvlc� Out piiUN
F9 --u9riarR mo boundaries of a wateraerwlce 7❑ii reHo^ —
If res.provide name of suppfler.
4. Location Of Proposed Well
cqn A _. S.Type Of Sewage System
Weld SE _7!4 or91e l v tµ )33
T-TOM�p H ors Range e ari Pdnr 1Aci�anSeptic tank/absorption leach field
a? ( I Q to-7 ❑E 6 ❑ Central system District name: _ -
iPiraa xti er.eu trap Armes(ip Svc Erns are typmMBXrot properly rr ,} — El Va181:Location sewage to ba hauled to:
.25%0 0 a from f N❑S 11-7,2 7.2 R.Nom❑E El W ❑ OUrer(attach campy o f end design mph)
Flu replacement welt aerlr-[Mom'apecradJm(MIT Od»e450-rrr+res
wetitcc�konedrols[tawir efeet dream; 10.Proposed Well Driller License#(vpiit5nafl: 4299
11.Signature Of Applicants)Or Authorized Agent
The making of false statements herein onr:stilules pas-- in Um second
Optimal: BPS well location information in UiM format degree,which is punishable as s does 1 misdemeanor pummel to c ri S
Requu-EA whims for GPS a,da areas Wows: 944_1(LE(ion..}- re...-.r....0 uwa auaw,iltlrns netoln.know Iry Contents
tius...rw. �i ttALnr3 bB wry at i w.....+�
[onettustumel3 . tn.v.7. —rlinwr.r.,ab„i.
Northing_ +W ILrRe} �o vitas must be Moles
z,. "`
°sun alrstbs NNW(cm* Riming [.. t .� //-7-0
Una rmtt bs set brow north Prix now 3 Goa
O ,
warevaw .r►❑ Er NO l iet)ft-t-rAr 5'7ol {°$a/r1,I_______
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S.Parcel On Which Weil Will Be Located Office Use Only
A_Yau must check and complete One of the foltowtag: •
laascsn rn;iww,. — nwrc,nw r,o- I Stigma.w.
Subdivision:Name / 4
Lot `p eioCfs_ �L FimylUnit Receipt_area only _____,_
❑ County exemption(attach copy of county approval&survey):Nerneitit
��p •
❑ Parcel lass than 35 acres,not In a subdivision.attach a deed with metes "►'� 7
end bounds description recorded prior to,fune 1.1872
❑ Mining claim Ram a rope Muir deed nr.....-%. 4
1x1 ls 5173f1g
15oiihill
tr�l as dean m Item Cashier ID: 91
O Square 40 ate
,I t..../
❑ Parcel of 35 or more scree(Oath Chad•and bawls desutpom or sway) SWAN .
O Other used, ing r •—
�
Check Purchase- # 5?Ri —
B. M. awes�parLrr � C.AroyouprometrrofMbwren VAR
`
fa ❑NC{Kno-4•0rrau} f
D.wi Mho no only maw aswed? YES ❑Noraao-prttem was)
TOPo
E. Soo Pared too Loos:not - - u
AR
—____ ass flt5r_i WD1 BA MD
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IRVAING. I
WELL CONSTRUCTION AND TEST REPORT I
KM STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Oflicaa Use only
j3133_hg11 L.,anfl18 De. r.CO O2 , .
RECEIVED
1. WELL PERMIT NUMBER 51OL,41
'2 OWNER NAME(S) VW/A,k--11-k }+ pv,d FEB 0 4 2004
Mailing Address OO1 - -
City,St. Zip Cam!l IN, p? WATER
RC$
?�M0) . J-4/98 - _ _ c°`°_d. !?3 `i
a WELL LOCATION AS DRILLF-D: -Q 1/4 A) 1/4,Sec..7 Twp. Al Al.Range (n 7 1A../
DISTANCES FROM SEC. UNES:
i/ n. nuui is rGy sba. kne. and 15 fat lt. from ( ie5"?- Sec. lie. OR
Lor L 4r aou?rj ow
SUBDIVISION: llu d LOT_q_BLOCK .-,2/ RUNG(UNIT)
STREET ADDRF_ AT iNT LL LOCATION:
41 GROUND SURFACE ELEVATION so f�
DATE COMPLETED r . TOTAL DEPTH /50 ft. DEPTH etomPth-TED___
15. GEOLOGIC LOG - - _ 6. HOLE DIAM, (in) From (it) To(ft)
Depth Denription of of(type,Sire,Color,Water Location] —la_ -
M34 GR fief R&.S & yrr 5O_
— 16. f I
.-r' 415 eZa- I_ 7.PLJUN CACINQ
On)t :_ a •--9a? _ r aka yQ /.3
- I "�
tL - f d. t PERF. CAS `G Screen Slot Size:_
cam._ _ ___ AV
4rd G` 5o-FT
� rJ
— a FUSER PACK 9.PACKER PLACEMENT:
m ilel I ype
Ste —
Interval Depth
10. GROUTING RECORD:
-- - --� _ -- — —Material -Amount Dens yllntetvel'-_Placerrlerri . T _
REMARKS: f t'404 7 5-4,14 3( $-'il PAcc..2v4
i. DISINFECTION: Type r #Ielgm, i4Ivp cbIoaVie_ Amt. Used ,_5a
2 WELL TEST DATA box if Test Data is submitted on Fonn No.GWS 39 Supplemental Well Test.
TESTING METHOD24Check
P Paapil
Ot l L reh +9O IL C4cf7'itaao mow:.aava "(fly' .9;.-..5— , Pf..Rlu4duif Nat CJ' J RII.
Pumping level „ {flit Date/Time measured If"(fly,'
7 5r f6— ,Test length (his.) 3 lac
Remarks
a I ba is reed the aaareman'made herein and know the comas thereof,end that they an true to my knoid►dge.Forward to Section 244-104 MO
C.R.S.,the matting of ides statements herein oonefilertes perjury in the wooed degree and to prxhishable ea a the rs 1 mtociaenaennri
CONTRACTOR Eh° weiveici 6_Amp J4fJICe, 4-1.-C- Phone (DO VI-- 36r-24' Uc. No. 1, `1 -
Maitisi4 Address 02 t mdm4t i i d, ai ari1 ('O E.0—5- -r
NernefTrde(P type or p"),.) Sig Date
s5:71 eL-- - ,l., - I /AA(
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