HomeMy WebLinkAboutProof of Water?rooþ wùer *o accnvn BLRE-OTLI- 667q
Sun inþ' Lasuþ'd'rÊ)
Form No.
GWS.11
0B/201 6
DEPAFITMENT OF NATUBAL RESOURCES
1313 Shernìan St., Ste 821, Denver, CO 802û3
Main: 303.866.3881
dwrpernritsonline@state.co. us
COLORADO DIV¡SITN OF WA RÉSOURCËS
HANc EG owN¡N NAMER ADDEIMAILING ESSR
TOPHIOR ïHtsCoMPLETNG SEEFORM,ONINSTRUCT|ONS stÐEEEVERSE POORINCOMPLETE,
OEQUALITY ILLEGfBLE FO CANNOTR[,lS PROCESSEDBE t]AN BEWILL HETUFNEÞ
74'l-4516 Email: stoddcd
Name(s): THESHARoN LYNN TODD 2005 TRUST
co 91621, sr, Zip:
Maillng Address: PO BOX 40tz
For Õflice Use Only
County:Garfiefd -
Well Name or # {optir:nal}:
I Per¡n¡I Number:1 1F2S3
FONCE LN, CARÊONDALE, Co 81 623
Floceipt Nurnber:02060768
. Case liJunrber(optional)
SE t.a, Sec.33 , Township 7 [ ru. or [l S" Ranse sz I e. or [J
Fi. Fror¡ f ru. or ffi S. rine, e47o Ft. From ffi r. or f W. i-tn*.
Address al Well Localion
F.M.
location of a wsll, use Form No, GWS-42/t the
w., ıTHSW rl+ ol ihe
lvjsion Name {lf applicable): GABOSSI
Dlstance frofi Section Lines:930
I Ctrect ff well address is same as owner,s ma¡ling address
, Lot 6 _, Block .-_ , Filing/Unit
mc{ai and that âm(we)the(we are)of wellthe irowner(s)described theknowpermabove,ofconfents the statements made herein,and thatsta[e Irrleare 1o my (ou This madetsknowledge.c.R.s,to 37-9f,,4a
s¡gnature(s) of the new owner Pieâse prinl the Siûner's Name & liTle Date
August 29, 201 9
the af newlhe ofownerrespr)nsibility wellih¡s to and this ItformpermltcornplBtesign an ts ênteriofagent lrformalíonslgningng pleaseseeinslructions.
r,
,dwr.state.co.
allow 4Please 1o weeksb for thisof form.processing Thereafte can oruewyou lheprint documentaccêpted
us/Wef lPermitSearch
Slåft Signâfure Date
Signåture of DWR staff indicates acceptance as a Chançe in Owner Name and/or Mailing Address
Fof Stall Use Only
Form314 closing/well trånsfer.html 64002393 {45591 1)
ilI Ilil]til]lliltililtlil
Well Constr.$cted.
Gsti.jrerL lml r .j-2:û1 :49 AM \J û
Receiptr t2fr6û]68 Divisionr j
Pern¡if #: 115253- - Water Di.$trict: ig
\4/ell Name ¡'#: County: GARFIELD
Designated Basin: Management Disrrict:
Case Number:
IffDID¡
Date Range Applisant/Owner Nam€ Address City/State/Zip
Unknawn - present ADCocK GENE 0278 RoN
LANE
lcE CARBoNDALE, co 8162:
.4.pproveil lVell Location:
Q40 Q160 Section Torvnship Range PM Footage from Section Lines
SW SE 33 7.0S 8?.0W Siì(th 930 S 24'lA E
Northing (UTlvI y): 4363095.6 Easting (UTIH x): 3180t2.9
Location .{rcuracy: User supplied
Physical Address
Ci$'istat€1zip
Subdirlsion Narnc
GABOSSI
Fiung Bloek Lûa
6
P¿rcel ID:
.A,rres in Tracf: 4,?5
\\
Date Issued:07 i23 /1980Date Erpires;
Use(s): DOMESTIC
Special Use:
Aquifer(s): ALL LrliNAMË.D AQUIFERS
Àrea whir:l tnay be irrigatcd: 1 ACRES
lVlaximum anuual volume of rpproprìaÉion:
Statute:
Pernrit Requirements: Totalizing Flow Meter
No
Cross Reference
Permit(s):
Permit Number Receipt Descrþtion
Commçnts:
Co¡rect County is: Garfield NOT Eagle
Geophysical Log
No
.A,bandonment Repoñ
No
.\VeII Constructiou Date: 04/07ltgS} Pump Installation Date: AS/24/lgB2
Well Plugged: Lst Benefici¿l Use;
Ferforatcd Ststic
Elevation Depth Pcrforated Casing (Top) Casing Water pump Rate(Bollom) Level
55 3û 55 30 l5
Lic
#Name Address Phone Number
Driller
PO BOX 815
BUE¡iÁ VIST4 7i9-395-3215
co 81211
BOx 488
Pump rnstatter 1106 p{-ArzeR,tor 35å!ï%nD s70-ee4,03rl
81602
0rvnership Change 07/0612û 1 0
\Fell Construction Report Received A4l]-?/ß84
Pump lnstallation Report Reccivçd 03/01/1984
Pump Installed 0512411982
lYell Constn¡cted 04/A7/ß82
Permit Issued 0'1123/1980
.Application Received Di/10/1980
ss4 #HoN,
Document
l{ame
Orieinel Filg
ChangE Lr¡-
Ou:ler
Name¡AdstcEs
Dste
lmaged
ßla\t2aa1
1113Ð12Ð07
Annotafed
No
No
@ 20tS Colorado Div¡sion of Water Resources. All rights reserved
t/i
Il
ItYÊJ.5,8r*. t¿
Applicatign rrìurt
be complere where
àppiicûlrle. TVpt or
Frint ¡n BLACK
ll$ No overctrikes
o¡ €rasl¡t3! unle3g
initi¡l¿d.
{1} Aff LlCAfvï - rnaìiing address
*Yi,/,u
çÔLORADO DIVISION OF WATFR RESCIURC.Êb
818 Ccn¡enniat Stds_, t313 Sh*¡man Sr,. Denvar, CÕlor¡do igOZO3
{
FOR: {
PERMIT FOEM
)-A FERMIT 1'0 r,'.qE GRout{f I wATF.R
14 ^
pÊH,Mn ¡ o (:oN.\ ¡ nì.Jr;f A Þ!t- LL
I Ä P[RMIT TO INSTALL A pUj'jP
1 FÉPLACEME'NT FOF NO. _------*-
RECE¡VID
JUL t 0t9so
qffffi
} OTHË.R
WATER CTUftT CÂSE NO,_,
FOB OFÊICÊ L¡SË ONtY DO NOT WRITE IN THIS COLUMN
NAME aÐ9 |Raceiptì\n.,.- lfrA-W ß
fltTr o-
TELEPHTNÉ T¡o-
{?t rocÁTrqil 8f PqûPOSE.O ryql-k
f,çunTy
-s4- l¡ af the
STÊ€ET
i."¡J*.Å
Froposed rütäl depth {feut){r/
Aquiler grgund wa¡ff is ¡o tJ€ ôtrtaioed trr)m
ft
Owner's wel I designetion z;{ 4
HOLD U,SE ONLY. n0 irriq;rtrftc (it
O,st
rsPB0ÍÐ Foa DorEsrrc u5E, rucl,uÐItË lEn
InfltcÀ$roÍ 0¡'ror 0tER 0$E .åtBE 0I'Bûld
cåñDEt8 tm lrÀrfis.
aP.g!!_cAr-tpN APPBOVED
PEB'I4IT NUT,dBEÊ
tl¿lï Ë i ss uÊ t)
txPlfì DA TF
H,Y
qgN g-rJ tgsjs oF a"P_E ßovAL
Tlris wr¡fl shall be,used in such.l way as Ig causeno rnareriai iniuri.r<.r existinq wäter r¡ghts. The
issr.r¡¡nçp rrÍ thc ¡rerrnil does not åssure the af¡frlicanllhat rlo irrjury witl occlrr to another rrested waru,right or ¡:r*:lrrr!e ¡rnother ownÊr çf ö vested wôterrit¡ltt frrrrrr sr;ekl¡¡g relief in a civil court iìct.ion.
llarrrr
tnp. ï -ã,Rne 8A... 4¿, /o# ^ ,ulN.Sr . t ìr,
{31 WATEB USE AND l,vELL DATA
Proposed marirnum pumping ¡ate {gprni - 1â--.
Averags Annual amount ol grouFd wåttr ,to bE âpprog;ared {acre'f etlti: .-- _ _/t 5
Nr:¡nb'er oi acres ,o u" rrrrn^r'ri,Æ.''.-..¿ -
lZ¡oì
%. Section ,.83 .- -
y'¿- r
I LrvË$ToCK {2t
l coMMEß0iAL icÌ
( ) orHË8 tSl_*
DETA]L THE USE ûN BACK !N I1'II
{4} DRILLER
Nãfiì€!,/
S,tr sc'1
o11 (0)( 1 rÑÜustllt¡xL i5l( ) llirllçìÀl ION {ti){ } tvttjNtcJPÁL l8}
,¡, t* "/,o/*.4.--#4. - ^F,/,,¡Íg -
rele¡,îrorre ¡ur. ?á2.'âÊ¿_ALic No _óJ._{
t"
/'o --{-:.-ıÉ.-.-- .- Çl.}.Nry 1
+ * + -+ * -l-- -þ-- -r-- --T- -. ; - +
Ur¡ the CEi¡TER SEÇflON {1 ¡¡ction.6il0 acr¿¡) for ths welt loc¡tioa
+
Ii.Lrr M¡LE,!?aS pg6¡
-¡r
¡+++-îf
t')l
t-
I,+
¡
I#EL\ M-USL å E toc ArEo, EãtçwÞy o¡r1ðncts lrom tectÌon t¡ner.
ft.t¡ot¡ - Sg #l - .r¡c.lino{ngrth or rosÈb}
{t. lrsm .- Ë+t / r¡c-tinr{rttl or wa¡U
ì,Y¡!ar
The sca
mült
snd lhc Ðre8 0n
dlagrar-n balow-
+
t
+
9-*¿
as?ã
$uB0rvrsloN
Lor f 6. rlocK -=--FrLrNË r---
.T
;^
I
+-
I
LNOBTHI;1+ I*.l*
I
{
I
1+
I.¡
I
I
{r}
f=gqATEg 6*n"r- €e-ár*t| _
No. of acres ¡1 ¿_g-Will rhir be
the onfy wetl on this t¡rct?
(81 PBOPOEçQ- CA$LNG Pg_ûçgA!!,r
Plaín Casing
å- , rn.rrorn -ú n.rcJ? tt.
_'-in" lrorn *--ft. to_ft-
Perforaled cas̡g
--á-
. in.trom--:E--rt.ro -{t. ft.
in. frorn- ft. ¡o- h
!---t*
I
i
LT-+
¡
ì
+-_+
-1- -þ
+J-
I
--+--+
.f ,i
-+*
I
It
ì*+- +' : + -- -+- '' +-
l¿ of the dìðqrå¡n is 2 inches - t mile
åch small 40 acres-
{9) FOB T,EILACE¡VìENT WËLLS sivodisrarrce
and direction from otd rvell Ðnd Þl¡Á¡lo¡Þlug!îngit:4*
WÂTER EOUIVALEN rS TÂÊLf rFtaund€d Ërgurr:l
An tcra,loof côcirg I rcrt ol Itnd I laûr .jåËIj
1 cubrc loçt Fér tacoñd lËlsÌ . . ddg grt¡gns Dêr m,rure igFmìrl ìarnrty Ot 5 wrfí ret¡vire tppror,m¡rl¡y I aere,lrot of *jr¡, 1,ç¡ yç¡¡I cc¡l.loo¡ . . d3,550 cubr¿ tr+t , . :t?å.gDO gárìôni
1.O00 gpm Ðuñ]Fcécoñtrnueujtv fot one das Jroducer 4 {? È¿¡€.frêt
{10} LAf,rp gÀt wHrcH gEj}ut{p WAIEBJI!_Lt.EE USED:
Owner(sì .=ï{/¿* &r{' * t-,'-
Legal de:c/iDlron:
Nç. of dG¡cs:,!1.¿ /
-r o
{lt) eETAìIFÐ QeSCnlp.flO¡l of rlre use ol grpqr.cl wa¡sr Hou¡ehold use and dom¿¡ric wells mu¡t i*dicete type of dirport¡y¡tem to b+ u¡¡d.ty'l /--. ^.1 f-'.
{12}ffit¡serlgn¡hlslal.rrJ.trtçÌtJd¡¡9*,ell3siy-oReqistratiorìaltrlY!alerÇourrCaseN¡.¡rnbers'
Typg sr ri4h¡ Usr'd icr lpurposel f)gs{:nÍrtrorì of Ja¡d on whlch u:edl
113) TilË ICANT{S} STATE{S} THAT THE ITVFORMATION SET FORTH HËFËON IS
L ä..
, ¡:'- ..
r,¡j , ' ,'l lr.¡1,,'t ti r'rlrr. ',¡t,rr ', 11 rn!r¡ !"ri
T THE B Hrs
wJñ-?F"77
te
THÌS þORM MusT BE SUB¡4IrT€O
Wl'lt{lN ç0 I}AYS 9F COMpLÊTttN
OF 'TTÊ WORK DESCSTBED ¡{ERE-
ON-TYPE ÛHPRINT IÀI ãLAC*
INK-
ADDRESS P.0, Box .t
t-
COLTRANO OIVIS¡ON OF WÂTER RESOUHCES
13'tl gþer¡¡¿¿ g¡¡ge¡ Room g1g
BËCË[v *-,'
MAR - t 1g&t
tenver. Cqloradô ËOZ0g , sIËR nÉS0URC[S
wËLL ËohtPLETION ANÞ PUMe tNg"IALLAîlon¡ R€pOFT -¡il¡ü,EnBlnE[n
PERMITNUMBEH 11525:- _
WELLGWNER Steve Kinney ____
Eqgle GountyS'd- y^ or rhÊ
.,- sq, ." ,. i sn"i3
DATE COMPLETED_ , 19 *
WËLt LOG
TOTAL DËPTH
t" ? -å-. n. 87. I[6 P.lvl.
HOLE DIAMETER
in- from_ to - ft.
in, from to -- ft.
in. f¡cm to'-=-ft-
DRILLING MËTHOD=-
CASING RECGRD: Ptain Caring
Size --- & kind ---_._-- frorÌr _ to --.--'-.-* ft.
size-&kind from_-to---=fr.
size--&kind from-to-ft.
perforated Casing
Size .*_- & kind frorn .._* to
-_
ft,
Size"_-&kind from--*to_-.*-ft.
Si¿e
-- & kind from ..--- _tq
-.-_-
ft.
GROUTING FECORD
Material
lntervals
Placement Method
GRAVEL PACK: Size _
lnterval
TEST DATA
Date Tested , .lg _"
statìc water Level Prior to Test
-
ft-
Type of Tett. Pump
Leng-îh of Test ?
Sustained Yiald tMet¿redi _.
Final Purnping Water Level *-..-.--
From To Type and Colo¡ of Material
Water
Loc,
Us€ ãdd¡tiaflåt paçês to
PUMP INSÍALLATION RËPOBT
Pump Make ñ {¿J.1 "
1
Type ., flou] rls . . . -- _ ..
Powered bv __F*Lec*si-c_--...-..* Hp -_å__
PumÞ Seriat Ns. JOiû901
Moror Serial No- _*33tå5891.ûÂfl¿_ -_*
Datelnstalleo 5=24-8å--..-*-.--__
Êurnp lntake Desth
Êemarks
WELL TËST DAT.A WITH PERMANENT PUMP
Date Tested
StatiÇ Water Levef Prior ts Test
Length of Tesî --.-- ._Hours
GPMSustained yield { Metered}
Pumping Water Level
Remarks
WÂTER
rÂFLg
cofiË oF
D€pRESslsr{
C0N T Ê ACTORS STATE MFf'JT
The undersigned. being duly n
Putop ¡ns18llðtion
thereof, and that the
5r gnature
State of 0olorado, County of
fsly Çomrnission expires: -,-
Notary PuÞlic
FORfvì r0 Bt MÀs€ oul ¡ôl ouÀÐßuþLlcÀt€
wHl le AÌ¡ o G RE Ë N cop'es müJÌ br tìlêd sirþ rh€ sÎðrô
oath, deposes and says that he is the cçntractor of the well or
read the statement made hereon ; knows thc cont€nt
L¡t{License No.
SS
srrbsc:ibed and sworn ro beîore -* th;sd-fhy of let +
re87-
: WHITE F{fRM ßU5r be ac ôriginðt cosy ùs borh :id€å Ònd aign€d_
Engintlr- Pln¡K COPY i¡ fo¡ rÌ¡a Ow¡Er änd YÊLLOu, COPY ii tÞr rh? û.rrtêr.
true of his
wJR"26_7?
-mrs foR0fïirJsT BE SUSM¡frEp
WITIIIN 60 DÀYS OF COii|PLËTION
, OF T}IE t^,OËK DESCRIOED I,IGÊ8.
. ON. TYFE Oñ PHINr IN BLACT(
ll\¡K.
WELLOWNER
AOÐRESS
DATE COMPLETED
Ûf
CoLoBADo DIVIsIoffi wA.rE R R EsoURcEs
1.118 ghcrmar $treet . Room glg
ûenver Ootors¿p g¡?09
WÊLL COfr¡tpLETtON AND pultlp tNSTALI-AT¡ON REpORI
FEBfyilTNUMBER ,15e53
Vill'i; ''
t'Ì:r": i.
AFRl!; .
f¡rÉ Ht¡:U;fg
$hIE Ei6Û'¡RÌm
5þ. _'rl¡of the-59 % ol Sec. 33- -
r. T. 3 .o.f.?-. w_P.M,-
$,ËLL LOÊ
, rg fl-xoLE DrAr'rErER
.-f in-rrom ô *o -5å¡r.
in. from
-
tô -=--- ft.
in. from
ÐRILLING MFTHO
CASING RECORD:Plain Cæing
f¡.
stze J* & kind S"J?ÊL trom Õ to jÇ _ n.
Size -..*.-" & kind frdm _ to -..---* fr.
Sí¡e -.* & kind from."=-.-,"-to-=-_-ft.
t*¡n¡
fro- - iþ to 4{ ttSíze .7
& kínd
Pe#orEtld}FAL{)
size._*&kind from_-to--ft
Si¡e-&kind Trom'-**-'to-_ft.
GROUTIiIG RËCÖRÞ
Material
lntervals
Placement Method
GFAVËL PA,CK; Size
,,
lntervðl
TEST OAIÀ
Ðate Tested
Sratic Water Level Príor to Test 5s
Type of Test Pump
Lengt¡ of Test R e5
Sustained Y ield {Metereól
reË
ft.
From To TvPe Color of Mate̡al Loc.
Use addition¿l pagÞs necesjåry ro cofilpl€re
55
Ri uttÕ¿to
t[o 5S Et*nD {,tn¡¿l
TOTAL T}EPTH
to
'55
Final Purnping Water Lewl
I
3s'
ïype-
ruMF ¡ÀiSTALLATION REPORT
Pump Make
%_
Powered by HP.**,
Pump Serjal N0.
Motor Serial No.
Date lnstaller _
Pump tntake Depth _
WATSR
1ÀBLE
Remarks-
WËLL TËST ÞATA t¡VITH PERMAi¡Er\¡T pUMp
Date Tested
Static Water Levet prior to Test
Length of Test Hours
Sustained yietd tMerered)*---...-*_._* cpM
Pumping Weter Level _
Remarks
COITT BACTORS STÀTË. MEfI¡T
The undersigned. being duly sworn upon oâth , deposes and says that he is the contractor of the welj orpumpinstallation described hereon; that he has read thå statement made hereon; knows the conlentthereof, and that the same ¡s true of his own
cÖ¡¡E oF
D€PRE5S¡OH
Signature
State of Coloradc, County of ? Écl*
License No.
SS
.rctá
frå+
Subscribed ánd
My tommission
Ëwôrn Ìo Þeiore me this f,- ¿"v-ot.At ei -
T¿EgrfË:ã:P',F ryo':rl*
.
Norary
FOFI!î lO eE MADË lH OUÁDÊUPLIûÀTE: wHrfÊ FOftM m út bû ön or¡gin¡l copy sD both ¡idæ ¡nd ri¡ntd.$rHlTf ANO GREEH coenrn urr bc {ilrd w¡th ihe StåtG Éeg¡n"!r- ptNt(COPY is f o¡ thr Owner a¡d YELL0Ìï COpy i¡ tçr lln tr¡ílh¡-
10"09-lû03 l5:ti frsm-BÅSÂL LiY I*01ô P !!Ï t-tû¡
itåme. äddIçsqj¡,nd pllonË of thÈ Êef$orr ctåimlnë $lyngtshiq pf the w.eu:
NAME(S)Gp-ne. Aclro. k
Maifìng Àddress c) ãl Ç\R..*,t^.. I a "lo
City, 81. Zp CL
rno.u r ï Q
YVET L LOCÀTION: Çourrty Ownet¡ WelltrêÉtgnâüön
CÁ
(tity )
slrr\lo orthe-,,ãfuJ4, sec. 3-?, r*p, J I ru. o, Es., nanse BJ il ç. *, Ew.i _b!Þ,r¿.
DistancerrornsecfionLínes q38,. Fr,F¡orn fI t'¡,orffis., +Lt+J 8Ërrro*8c.or,Üw un*.
+
".-t
The above llsted owner(s) say(s) thalÞf, she (they) own the welldescribeci herein. The existing re.cord is being
silended lor the íollowing reasôns: i i Change in nam€ of owner L-i Cnange in naiiin€ address
D Çorrection cf lotätlon for exernpt welfs permitted prior t0 May 8, 19?2 and nofl-exemÞt ì'vefs pe¡nnitted before
May 'l7, 1965. Pleasa seatfie æversg çirlr forfirrt¡er information regardinê ÈÒrrêc{iorl of the wêIl location.
Na Lot
I (we) dain and say {hat I {we} (arÐ the ov/nër(s) of the y\¡etl descdbêd åbovË, knaw tre Êoätents of lhe
slatemënts mada hereiñ, ând ûtete that thêy are true to my (our) knowledgc.
Fora,r
No.
Õ\us-lt
6/2003
$TATEOF COLÖRAÞO
OFFIÇÊ OFTHE STATÊ EN6I{\IEERglg CênGnfiiâlBldË., 151s Sheman St., D€nvsr. Co E0Z0l
{303) 8öô^3581 Fax (303} 86Ê-35ss
CHANGE IN OVII}¡ERSHIP/AD DRE$S
CORRËCTITFT OF THE WELL LOCATION
lnseÉ the Well Porrnft Number r tq
f,ECEIVEI)
0tT 1 4 2003
"'åìli'H;''æ¡'
For OfEce Ure Only
o'1,ç6 0'tþþ
fhit lq.* ie filød.by the naned _indlv-¡du8Voñlity claiming that ttrey are the owner of the well permitted äs rËfêrenced abgve.
Tnie fÌlinn îs made pursuant to C-R.S. 37-9t1.1{t.
PIeåÈe print ìhe stgnefs Name & Tltlè
Õ;tü ne f*
C*C.n e f ,¡a- L
the ÞatÊ
c
It is th8 responsibility ot thë ne\ô, ov/Êer ôf th¡s wéll !c complete and slgn the fann Signatuêr of agents aæ accept?ble if an
original iefter ol agenry signed by the orvner b adachsd to the I'orrn upon ths recelpt.
#¿ a Åú^if; 8,ffi i?^tr ft f,iåüEEdi. oivNERs HrP
to'If -#
Fcr Ofßr Us¡ Only
Sffe EûTIEÊCT Þs¡o
€wJR-?Ë-77
TfiIS FOAM MUST BÊ SUFMITT€ D
WITHIN 60 ÐAYs OF COMFL€TION
OF THE IVOËK ÐÉSCÊI8EDHçRÊ,
ON.ÎYPE QR FRINT IN BLAÊI(
tttK.
COLORADÛ OIVISION OF WA"TËF RESOURCE$
13'13 Shemran Straet - Room 818
tenver, Colorado 8O?03
:,
WELL COMPLETION AñID PUMP INSTALLATION REPOET
ßECËlv -,
MAR - 1 1984
TATER fiESûURCiS-llü¡.glß¡NEÉa
É
Ðagle County
y. or rhe -". SE y olt s"..jj
PERMIT NUMBEB l'r5253
WËLL OWNÊN Steve Kinne v
ADDRESS P.O" Box.l-
0.
OATE COMPLETËD
--
. 1g
-
WELL LOG
ï. 7 *-S--. R, 87 1.¡. .6 P,rvr.
I{OL[ DIAMETER
irr. from to _ _ .. ft"
in. fr6¡¡
-
to
-*
ti,
in. from to .-- ft
DRILLING MÉTHÕD=.-
CÂSING ftËtORD: Plain Cating
Size --.- & kind
-'==_"_---
from
-*
to --_-_= ft.
Size
-=*
& k¡ftd from _-- tö
-_-
fr.
Si¡e-_-&kind from--_to_--lr.
Perfor¡tcd Casin$
Si¿e ' - & kind .^-_'_.-__ from to .-- ft.
Size -._ & k¡nd from
--to
-------..-- ft.
Size
--
& kind from ..-- to --_ ft.
GROUTIÈ¡G HËCORD
Mäter¡å¡
Intervals
Placernent Method
GBAVEL PAGKI Siee
lnterval
TEST ÞATA
Date Tested , 19 *
Static Water Level Prior to Test
Type of Te¡t PumÞ
Length of Test
Sustáined Yield fMeteredl
-
,
ft.
.TOTAL DEPTH
From To Type and Colçr of Materaal
Weter
Loc.
Use edd¡tionåa rrecefsãry tO cOmplete lOg,Final Pumping Wâter Level
PIJÎVIP I NSTALLAT'ON R EPOÊT
Pump Make {) {J+1?1
ïype
Powered bV -glee*ní¿-_ Hp --å"_
Pump Seriat No.30gol
lvlotor Seriat No. _3"SLå'5Sgle.ê"BÊ__ -_*.
Þate I nsralteo _*__5:2+-=.ee__**- _
Pump lnrake Deoth __ 441
WATER
TÁBLE
Remarks
l¡¡xd
?'WËLL TEST ÐATA WITH PERMANËNT PUI\ltF
Date Tested
Static Water Level Prror 1o Test ___
Length of Tesr ._.__ .
Sustained yield ( Metered) -*
Pumping Wate¡ Level
Remarks
Notary Putrlic
FORM TO ÊF. r^AOf OilT +
WHllË AilÐ GÊEEN cot¡c¡ mu¡r
cottE oF
ft€PRES stoü
Hou¡s
GPM
CONTRACTTRS çTATEMENT
The ondersigned, being duly oäth. deposs$ änd sðys thai he is the contractor of the well orpump inst¿ltation descri has read the stâternent made hereon; knowg the rontent
thereof, and thär rhe
si gnature License No
SSState of Colçrsdo, Counry of
Subsc:ibed and sworn to betore ,¡e rnltråÊHlv ot ,'tggs.
lr'1y Cornmissíon expireç: --.-l, *Æ-l -._- , ]s t7
LÀ)
lv ûlJAflRuPLtÇl\ÎEr WHITE FQSM murr !,r àn ôtigiûä! Éo,pï urr tÆlh *idã urrt risnetl.
t'ê lircÉ wirlî the $rätt Engincar_ Ptlt¡K COPY ¡* trr thË ewner ¡nd yELLOUJ COpv ;s {or thÇ Or¡rtèr
uaL
true of his
;¡t_-4rh.r4. rr
çOLORADO DIVISION OF WÂ,TEB ÊESOUHC:Ëh
818 Conrennial Bldg,, I3l3 She¡rñan Sr., Denver. Cotorado :gO?Oi
Pl-E_!,l_!r APPL tC ATtoN FÐRM
. ) A PËFMtT lo tJsË. GROUT,¡Í) '_"jATF.R14 A FERMT I I0 {:(}N.{ I nU(jT /t Llt LL
} A PERMÍ T Tû INSïALL A PUMP
} fiËPLACEfuIENT FOff NË. ,-.-
I OTHEN
t/
ìr lJ.5' Rr r.' ló
Application mu*t
be cor¡plete where
¿gplic¡tf¿. Type or
p<inT in ELAÇ K
lS!. No everurriker
or €råtuto3 l]n¡çs¡
inîrislrd.
(
(
FÕÊ: (
I
I
RECEIVED
JUL t t 1gs0
æå,Htr¡n
{T}- mail¡ng addrers
NAMË 3t
STÊEET
CITY .1""¡J*.Á ./n.
(9r¡r r,
TÉLËPHONE NO 9/e -,FPd */
QI
Cnunty
1ó ot the
Proposed toþf dêpth (têst,{r/
Aquiler Sround w¿ter is ro ¡'e ôlttaiñed fr(>rni
|VATES COURî CÂSF NO,--
[ìår'rr
Fe.ceìpr., - -lgÊ3þ ß
FOÊ OÊFICE USg ONLY DO NOi WHITE IN ïHIS TOLUMN
r*p. Y -fr,R¡s..f!. *A, -,áÊ-_¡u.1N'61 'l .19'
13) WATf R USE ANP WELI= DATA
Proposed maximum pumping rare (grxnl - I â_-
Av+ragc ð'rnuål åÌr,ounl of greund war(! - _¿
10 be åpÞropriated {acre.fer't}:- -/.:_á
Numbc¡ of açres ,o ,r****lÆl-..1
lf"
flc(ft
f } LIVESTOCK (?J
Í ) col$MEnctAL {ál
ll,st
å.PP8OYIS FO8 ÐOIÍESTTC USE. ISCLTIOITS TE8
rRRICÀTI0ü 0F lr0[ 01¡'gR osE .{cRE 0p Eors
0¡¡Du8 tm IÁrÍ$.
åP P ! l-c êr. I p N 4 LPjq-v_ag
ÊÊFM'T NU}IBER
Çp ry crJ.T I Qs¡.s_q EaEgEayat
This weil.lhalt.ire .useci in such iì wöy â$ fo causen{} rnâreri¿ti injuri. tQ existìng wðter rìghts- Thê
issu¡¡rcc rrl.thu ¡rerrnit does nst assur.e the;frplicanlIlìilt rìo injury will ocçur to another vesred waterright or i)rr'clr¡(le ¿rncjther çwner of ð ves¡ed waterriglrt frnnl sceking relíef in a civil cuurt ¡ct.ion.
I,
ùvner's urell ds5ig¡.1¡ra 7 4
USËHçLÞ ¡rs6 ONLY no irlgarro¡t {01( )fNtl!-tsrfttALiS)I I rlt¡ttG/\] roN (0|
i ) tuliJl\JlC,PAt l8l
I I OTt-tËfl ts)-*-___.--.*
DEIAIL THE USE ON BACK tN { lil
{4}.pñtLLE¡
l¡r.Ì;\'t Ë issuËÍ)
ËXPI R Ui\ TË
J_J UL
ULName
5rreel J
City
flY
ID 1TerÈr)r,c:ro *, l6.LâE¿-eLic. Ni>. -/é-{_f_-Æ__
F
(;()iJNTY..
t
1
(5)ï.t.1å bocAËory grJHË, pRoposEÞ WELLwnrcn ulr wlÎEr wilt Þr uúsd musr Þâ indicsïfti on thi {6) BEJ,.pW
Þy or5lsnisr rrom 1ec1i0ñ lines,
end lhr ¡roo on
di¡grom b¡low.Un tha CEÊITER SECTTON l'l rpction, 840 ¿r:rerl lur thð w6ll lÉcâtlon
9Bð {t. lrom 8o*il ¡æ,lirro
^--â.42ê-'k.r¡om
(n€rth or ¡iru¡¡¡
Eno /
+ - + * + - + * -l--. : -* .-r * -j- - +
-þ
i
I
I
I
J*
1
't'
-+
I
-t
i
I
+
tì
UJ7
I
lfroßTH!;1
i t-+l*
i
+--þ
-¡--+-+
it
l-t+îir
i,r1-*--ï
lr .. r MILÉ, É?8o FEÊr
-+l+ + -i' -r -í-
I
E -.,
Loï { Á.-sLocK
-FrLrNG
r *-
r-tJ¿susDlvlsÌON {.**ét z? ' , , ,,., ,*.-
t7l
L.oçALHg owner:
- lri¡t ır ñäl--
a*#
No, ol ac¡es 4al Will rhí¡ be
the orììy wel[ on this t¡rct?
{SIPROPOSED CA,STNG PÊOGFAM
Pl¡in Casing
.r'r
---fu-*in.trom lÞ. k.rc /ê-h
toc, linr
+
{t0}
öwnertç)
Leçal descriptro,n
* + -- +- "- -F- -- -+-
-l- i
II
-+--+
J----T-
_.--in. from
Pe¡forated ça:ing
..-6- - in. trom
-...-..---*ft, to..---ft.
a t.rc lQ .*.
i'r
-1-*
in, from fr. to---._ ,.t
. ltATeÊ ÊOU'VALENf$ Ì-Á.ELE rFornded F,gurest
Àn rcrr-foo¡ covlr? I !c{a of lünd I loot .trcil
I cubrc lûÕ! tr€r tâCÖnd iÊffl , . ¿49 gtltoñt Fpr ñ¡ñure içfrql
,4 fåmrly Ol 5 w¡ll .?quire tpp/o¡¡ñárerv I år'e,f qa! ot wjf ?¡ l,ur yc¡¡
1 rc'r'toer . ¿3.5SÐ cubrc tàrt . .l?5.goo g¡iioei'l,0Ç! gerh Ê¿rtnpÊd coñttnuov¡lv fo¿ one d¡v t.sducÈ¡ 4 á? acre.fcer
The scale af the diagram is 2 inchr¡s ' I míle
Each small uåre esenls 4û acre¡-
&.{" * =,'
19) FOR B qP¡-A,CÉlû ENT WEJÀS sivadisrance
and direcr?on from oló wÊl1 ¡ñd phnt for Þîugûingir: r/*
,/.¡/No. êl ¿c¡er
0
I
I
ì I
(11)of ¡|r¿ 1¡5c' af qr91¡¡¡çl p¡¡"r' Householrj ure and dome¡tic welf¡ mslt indícaæ typeof dirporl
¡y¡teñr to u¡cd.'y'/ /.. n-l Ë=.'-
{12} QTHÊ8 ry\-TËR nJGHTS r¡serì on r}¡¡s l¡nd, rrrcluclrng walls GiveRegistratiorr airl Water Courl Case Numbe¡s
Type or righr Used lo¡ {p,rrtrose) f}escrrftlon of land on whrch used
(13} THE ICANTIS} STATEiS} TI{AT TI{E }NFORMATION SET FONTH HEREON Ig
HIS K E.
',tì . .. ,,t Jr,r1¡',1 rl irùrtr. '-lr.rr,. 11 r|,ì1j.r:"1
T TH€
I