HomeMy WebLinkAbout20150088.tiff COLORADO DIVISION OF WATER RESG_.<CES Office Use Only Form GWS-44(7/2012)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER,CO 80203
Main: (303)866-3581 Fax:(303)866-2223 r1J≥ermilsonlmenstateco.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.
1. Applicant Information
Narne(s) — 6. Use Of Well (check applicable boxes) —
EUDEN & BIANCA BALDERRAMA See instructions to determine use(s)for which you may qualify
❑ A. Ordinary household use in one single-family dwelling
Mailing address (no outside use)
14440_HARVEST MILE RD _ _ • B. Ordinary household use in 1 to 3 single-family dwellings:
City State Zip code
BRIGHTON CO 80601 Number of dwellings: 1
Telephone(w/area code) E-mail _. •Home garden/lawn irrigation,not to exceed one acre:
303.356.4470 ITRIPLEBTRANS@GMAIL.COM area irrigated 5500 7, sq.ft.R acre
2. Type Of Application (check applicable boxes) M Domestic animal watering-(non-commercial)
■ Construct new well ❑ Change source(aquifer) ❑ C. Livestock watering(on farm/ranch/range/pasture)
El Replace existing well O Reapplication(expired permit)
El Use existing well O Rooftop precip.collection 7. Well Data (proposed)
❑ Chanae or increase use O Other: Maximum pumping rate - Annual amount to be withdrawn
3. Refer To (if applicable) 15 gun 1.5 acre-feet
Total depth Aquifer
Well permit t( Water Court case N
500 feet LARAMIE FOX HILLS
Desgnated Basin Determination a Well name or/ 8. Water Supplier
Is this parcel within boundaries of a water service area?I❑YESI l NO
4. Location Of Proposed Well (Important! See Instructions) If yes, provide name of supplier:
County 9.Type Of Sewage System
WELD SE _ 1/4 of the SW 1/4
section Township Nor S Range E or w . Principal Meridian • Septic tank/absorption leach field
22 2 Ilxi f- 66 0? P-4 6TH ❑ Central system:District name:
Distance of well from section lines(section lines are typically not property lines) El Vault: Location sewage to be hauled to:
1710 Ft from lTN IRS 1527 Ft from CtE lW
For replacement wells only—distance and direction from old well to new well CI Other(explain)
feet Direction 10. Proposed Well Driller License#(optional):
Nell loea(on address(Include Goy.State,Zip) In check it well address is same as in Item 1 11.Sign or Enter Name of Applicant(s)or Authorized Agent
15369 CR 18, FT. LUPTON, CO 80621 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
Optional: GPS well location information in UTM format GPS unit settings are as follows:
thereof and state that they are true to my knowledge.
Format must be UTM Sign or enf Jame( t person - omnlin ,cation Date(mm/dd/yyyy)
1-Zone 12ol!f' Zone 13 Easting:. — i a //
Units must be Meters 5d-J,6`57,65ga. x0/23//'4
Datum must be NADBS Northing. 1111
Unit must be set to true to set Datum to NAD83 ue northIf sign
innnntn Ale
GPS unit checked for above? DYES tJ z- ✓ �NyA d.ra,,f
5. Parcel On Which Well Will Be Located Office the Only \
(You must attach a current deed for the subject parcel) uses map name - - DWR map no - Surface oleo
A.You must check and complete one of the following:
❑ Subdivision: Name Receipt area only
Lot — Block Filing/Unit
• County exemption(attach copy of county approval&survey)
Name/# RE-4704 Lot# B _
❑ 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
❑ Mining claim(attach copy of deed or survey) Name/#:
El Square 40 acre parcel as described in Item 4
❑ Parcel of 35 or more acres(attach metes 8 bounds description or survey) AQUAMAP
❑ Other:(attach metes&bounds description or survey) WE
B.S(of acres in parcel I C.Are you the owner of this parcel? WR
22.532 I rV YES Cl NO cwce
D.Will this be the only well on this parcel? RI YESUT NO(if no—list other wells) TOPO
MYLAR
E. State Parcel IDS((opnonag
5B5 DIV WD BA_ MD
WATER SUPPLY INFORMATION SUMMARY
Section 30.28.133,(d), 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.
1. NAME OF DEVELOPMENT AS PROPOSED
2. LAND USE ACTION 4/5
3. NAME OF EXISTING PARCEL AS RECORDED /chi ,'G RC-.9(7oaj/
SUBDIVISION FILING BLOCK LOT
4. TOTAL ACREAGE ,5 5. NUMBER OF LOTS PROPOSED / PLAT MAP ENCLOSED 0 YES
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
B. Has the parcel ever been part of a division of land action since June 1, 1972? 0 YES 0 ND
If yes, describe the previous action
7. LOCATION OF PARCEL • Include a map deliniatiny the project area and tie to a section corner.
5� 1/4 OF 4)4) 1/4 SECTION ZZ TOWNSHIP Z MNOS RANGE be 0 E z W
PRINCIPAL MERIDIAN: '171 6TH 0 h,M. ❑ UTE 0 COSTILLA
8. PLAT - Location of all wells on property must be plotted and permit numbers provided.
Surveyors plat lit Yes 0 No If not, scaled hand drawn sketch 0 Yes 0 No
9. ESTIMATED WATER REQUIREMENTS - Galloaa per Day or Acra Fast per Year 10. WATER SUPPLY SOURCE
❑ EXISTING El DEVELOPED 14{ NEW WELLS -
WELLS SPRING PROMO AOUFERS (CHECK Mn
HOUSEHOLD USE It / of units /75_ GPO . 2 AF WELL PERMIT NUMBERS ❑ALMA 0 UPPER ARAPAHOE
C7 UPPER OAWSON 0 LOWS ARAPAHOE
❑LOWER DAWSM LARAMIE FOX HIM��"COMMERCIAL USE # r of S.F. 3D GPO d3 AF ❑MYER ❑DAKOTA
❑OTHER
IRRIGATION Ft ./z of acres 250 GPO •Z6' AF
STOCK WATERING # /0 of head 750 GPO • 1(f Al 0 MUNICIPAL
O ASSOCIATION WATER COURT DECREE CASE NO.'S
OTHER GPO AF ❑ COMPANY
❑ DISTRICT
TOTAL /Z05 GPO /. 3j AF NAME
LETTER OF COMMITMENT FOR
SERVICE ❑ YES ❑ NO
11. ENGINEER'S WATER SUPPLY REPORT 0 YES 0 NO IF YES, PLEASE FORWARD WITH THIS FORM. (This may be required before our review o comploind.)
12. TYPE OF SEWAGE DISPOSAL SYSTEM /5/2
X SEPTIC TANK/LEACH FIELD 0 CENTRAL SYSTEM - DISTRICT NAME
❑ LAGOON El VAULT • LOCATION SEWAGE HAULED TO
❑ ENGINEERED SYSTEM Unach c copy of anpinsurine Mien) ❑ OTHER
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