HomeMy WebLinkAboutWell Permit Docs,AIA"'," Vg4*tlTl'vY P- -
1Yffilt't'ivtv
Form No.
GW5-11
08/2016
COLCRADO DMSICN OF WATER R€8OURCEs
AEPART&SNT OF HATURAL RESOURCES
't$13 Shorman $t., Sts 821, Denver CO 80?&3
t303) 866-3581
dwmenn itsonlina@sta{e.co, ua
CHANGE IFI OWITIER NAMEIIIilAILING ADDRESS
PRSOR TO CO[dPt.EB]tG THIS rORS, $88 3!t{rT{Ufl19r{$ gr BSVEnSE S|OE
, l|{es{*pLETE, pooR eu*LrTY, oR tLLcGr&Lt FORfitS CANHOT &E FROgESSE9 A}tD wlLL BE RETURHe'
Naryp. a"4draesgn4 phone n{trrh@f sl oer$o,n clsiming.ellmetsh;
Neme{e}: Lticinda..4&stertind and Dcn O. Weet$rlind al3d Kylie q'onr*l*z and frlkl3qnq*l$f__
Enr*ir; t;-ii5{.1q-11i'ld 9$l *itttt"if , f cr*rrna*e; { f'ls }tiL-_egi$J
Ciiy, S{. Iip:R!l?e.CO S16s0
Mniflng Addrose:1359 CoL,nV Road 294
For Offtco Uoe Oniy
l-" '.tr(if.:l:..,.
fi$ ,., '' )
G,,. . {' / t!; ,,
t t.':,)'.,j 'i t t; -f{frG[i,ifE8,, ],,.*.11;....,",.
IrtAR t g lfr,1g""'t''
'&Af€R tC[:$()Ut{C6$
lir;Atg Ef{*tt\igtq
f\{\1 l}
t*lkY va of rhe SE 1/4, sec. 1q , Tovrnship S il N, cr$ $., Range S3 , n t, orE w.,
&istance frorn Sestion Linee: .?,22$* . rt. *o* F N. orfil $. Line, 1, !?9 Ft, frcm f,le. nr f,W. tine
NOTf,: lf ch*ngingla*necting tfte psnrritted lscation o{ a watl, uee Fsnn tqo. SWil2
Wslt Pen*lt l*n*mbsr: 12120f]Re{eipt
WH!-L LOCAIIOiI|: Counfy:Garfield
6rh
Case Nurrber {opti*nal}:_
$u trdivi*i*n t{a.^rts {tf appflcabie};, Lot *.-, Flack __*, Filing/Unit
p.M.
1 aE.A Road ?94
Gily $tBts$ireet Address ai Well Lecalisrl
ffi Ctrecls if lvell addreas is same a& swnar'$ maillng addree$
Woll l"Jame *r* ioptiona!);
Rille C0 8lSsS
| (!v€) ctsim end say thet I ar* {we ate} th6 swner{s} sl trhe well pannit do*cribEd ah*ve. knaw the sontsnt of tha $hlemsnte rnads heroin,
6nd stato that they er@ true to my (oc*r) kncwfedge. ?his fling ie made pur3uant to C.R.S. 37-S0-143.
Plaaee prin{ the $igner's Name & Title
Kylie Gonzalez and F itlz Gonaalea
Ow*ar
Dsn (}. WssterlindLucinde Weetertind ,qhr,lfi
,,f Iqltct
Dste
#i6 the ronpofcibitlty sl*** ne*bwn;;f rhi$ wslt psrnnit ts conrFtsts and si6n thlr fqrm. if an agent ts sfgning or e*rdring *lt*rnLtion, pts$ss
se€ instructians.
Ffesp* ellaw 4 to $ weeks fer pro*es*ing af lhis f*nn. Ttrereafisr. yru cen view er print ttre seespia* docl!*ne*t ai:
hltrr :1/vrww,dwr.st&te.{a.ueAiJellPsrmi}Qe*ret1
$
$
s'
acceptence ao a in Pwn*r Name and/or Mailing
For $tafr U*a Snly
j " tt'f t\
Dat*
CSLSRAtrO
fr ivlsi*n *f. W al*r &eeofi v*e*
i.)t: .t;;l I tn":'x t ;l f,i,r",.D1 *l ii+r,::tit e*,,
WELL FER#ITT HU'd&EF.
BEfEIFT I{t'i*gER
, ?r20&-
9{1{64&
o RI&THAL FEftA*rT AFFU{Ai{T{' }
r.AY R$SErr W & 3&r"lSRA L
*FPf;WEF WEL L.-LSSAT ICIIT
lftf*terDlvision: S Waterglstrlct: 3S
D*eignated B*ein: NIA
ful*lr*gerlerelDistrift NIA
C*unty: GAFFIFLD
ParelNamg: N/A
Physical AddreEe: 13SS COUNTY ROAD e$d RIFLL CO S1€50
FIW I /4 SE 114 Ssetien 10 Township 6.0 $ Rangs gS.0 W $inth P.Art.
$ff*..CffiFgt t{*TE$,,i#qe*rg, IpryE 1,3, !*Affi3}
Eesthg: fAlg?*"C Northing: 4]&28?.9
pe can
ng ths Well Perrnit $*arch Tacl atr**r,ry.r#F?ar.steb.ss.us
gate $ssu€d: T lXt1981
tsxpirafion Date: 7 131 f 1V8t
w-rs"wlfi
fi$"1ff-Slg
fifr-1$-t01s
&s 1s-s0Jg
$HAh,fiE tru OWhIER llAft,{ErMAlLlt{G ASDfiE$S; SH.&tilGED TO LUCIF{nA WESTERLIfIIF
CHANGE lN (}frf r'{ER NAhl[E/h/tAll-lNG ADDRESS. CHANGED T0 DOFI OWESTERUND
GHANGE !F-l *'wl{Efr FdAertErMAlLlFlG ADDRE$S. Cl{ANGED TO l{YLtE GOhIZALEZ
CHAI.IGE IN OWF,IEft NAMEMAILIhIG ADDRESS. CHANGED TO FE1TZ GONZALEZ
Print*d S3.3q"2*?9 Fsr qu€Etiff|' Seit this F€,nfitt calt 3*3"8*6.3S1 sr qs ts wtihd-r{at€{"st&t@.Ns.r!'Page ? of t
roRM FO.
ewE1l
0?/!8
STATE OF COLORADO
OFFICE OF THg STA]E ENCIINEER
818 O(irt rnhl Hd$, 1313 Shcnllfr &. Ilrnr. Oobmb 8H$
$0q 88&3611
pRIOR TO SOUHSI$$S FOnH, .ScE lttlSTRuSIPt*B (,t{ REI,ERSE Sffi
CI.IANGE IN O$N.IEffiHIPIADDRE$S / LOCATION
tlll€rt pcnf,r, ulEgrocKT*ru( oR GRooffi ooilrffitluAll
1
0cny, st, ztp.,."... .....*.l'.f.}e"r.....s.9-........-g
2 rHB CITANOF r€fQR OHE OF THE rOILOlffiN9i
E
n
n
For Oficc ih.qrlf
. rl.t f-: 1. | .,::
0gT i s isgs
.\r.tt l, ?tr , L !'. i
-;r': i rf,,l{l !;
i't *'
g.
..,...}I.fg,,,. t1+olu'....^...$.8...l/d $ec,.....1.g- ,.tnp. 6 .. ... [J*. *E
Dist cgq trorr gacllon unrc ...?..,.?.ilfi...^*. Ft trom n N. o, HI g.
(ohr) (sil0 W
s., Rar€o'"g.p. nE * Elw. ..nth. p.M.
r.he, ......L.r..1?.g ... Fr, frffii ill r" * il *. u*.
olvilEfi'$ wEu bEst€1ffIu1N ....,.....^.............
Rif ra eo I't 65fl ".r.
SubrlMsbn.,, Lrt
,1,
t The ahsve lis.ad own€r(s) say(a) thaf ho (fisyl orm lha dn cfi.mt dtrcrlb€cl hsiln.
The adsring rcord ls baing amen&d lorthe tulbudrg reusut(c);
ffil "*nr tn nam€ sf svner. fJ *tu. tn rnrstrg drsss.eofiKtdr of locdon.n
s,I (we) han leed the smsmsnB mad6 hsrln, krnr the ffitartr thff.ff, uld dt|io $et thry cm true
to rfiy {our) *norladgn
[Pur8uer[ to $*,tlon 944-104 (lgXa] C.R.S., the maklr€ otfshB stalsrsrlb herin consiltutw porlury ln
tfie second dagrea and is punlshabls re a cl6ss 1 mlsd€msrur.l
Ngma/fhb Osw Oirnsr) Pleasg typa or prinl
Robert W. Lay
$andra L' Lay #rtr,'g-
sbrHll.re (ibwormo
)o."ta-9.f
Dde
FOR OFFItr USE ONLY
ASA ou{ERstftp
A I
Strte Flr€|'mor od
Oourt Cw No. Olv. Co"gash-- MD:-;; .
L
Ugb
"-\-
t_)tt
IwBJ.25-7 6
TYPE OR
PR'NT IN SLACK INX
coPY oF;ccEFTED
sTAT€MFNT IlAILED
ON REOUESI.
COLORADO DIVISION OF lrvATER RESOURCE
8,l8 Centenniol Bldg., l3l3 Shermcn St.
Denver, Colorodo 80203
STAT E OF DO
5 RECEIVED
MARo4pq
TATER ilESOUflCEI
AFFrDAfir+tnifrrltf3
SS
COUNTY OF
-t/ sTATEMENT oF BENEFtoAL usE oF GRouND lyATER
AII{ENDMENT OF EXISTING RECORD
LATE REGISTRATION
PERMIT NUMBER i el aoa LOCATION OF WELL
t Aprorrrre t1flt-t-SatrELD-CoufllyIHI AFFIANT(5
who:e moiling
oddress rs J 4Zr rtJ &J of tl,e Sf Z, 5ect,or, / A
c,,y ftt f It Q-o la 6s n"n %l= t") 6
lF {p r\r
l,
'N OF 5r
PM
l/tt,
rote cloimed hereby ;s -,lO * ., gollons per minute; the toiol depth o{ the well is
o{ wofer io be diverte a ;, I !* - ocre-fee't; {or which cloim rs hereby mode for
being duly sworn upon oolh, deposes ond soys thot he (they) is (ore) the ownet(s) of the well desctibed hereon, the well is
lccored os described sbo'e, ct distoncos "( &aA6* feet from tl" $4-AIt.* sec?ion line ond Jc/.* {eet {rom the
f;+,T+,,.eclion line; woler {rom this well wqs {irst opplicd lo q beneficiol use {or the purpose( s} described herein on rh" {$]
doy o{F-EA , fS f;*,te moximum susloined pumping rste of lhe well it lO t- gollons per minute, the pumprng
Ld6 {eei; the overcge onnucl cmounl
(--
purpose(s), the legol descriplion o{ lhe lond orr which ihe woier {ronr this well is used is
s{trt€ As *8oo a of which
t
i--ocres ore irrigoted ond which is illustroted on the mop on the revetse side of this form; thot this wel I wos completed in
complionce wi th the permit cpproved therefor; ihis slotement o{ beneficiol use oi ground wcter is filed in complionce with low; he
(lhey) hos (hcve) reod the stctemenls mqde hereon; knows lhe conlent thereof; cnd thot fhe some ore true of his (thelr) knowledge.
COMPLET EVERSE DE TIJIS FORM)
!ignoture{ s)d-
Subscribed ond
to before me on {kaz*,w LArhisdcy oi
My Commission exprres
/-1o td'
ACCEPTED FOR FILINC BY THE STATE ENGINEER
PIRSUANT Tfl i'HE FNt LOWINfi CNNDITION-!:
swof
F COLORADO
ACffiffiPTHD
./ ;-" r /,(A o-d",1 l '
sE'P 3 6 1983 Asslstant
FOR OFFICE USf ONLY
Courl Co:e No
or !.
Weli rJ:e
Mo
*{
5e t,
I
.. v'
o',' qff=-Bca,o --.- --- [ron n'1,
ooY
a3
OaTE 1'AT' F:lCINEER l.\
Wel I drilled by (/4ru t,Jg S sc
tfP erm onen t
Pump instolled by it fr
Lic. No
Lic, No 7q /
Metcr Seriol No n F lo* Meter, Dote lnstolled
Owner of lond on whi
woter ls being used I 'l
TIIE LOCATION OF TiIE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS TI.IEAREA ON WHICH THE VIATER IS USED MUST BE SHADED OR CROS$IIATCHED ON THE oIIcnl,u aeuoir.
This.dicgrom represents nine (9) sec(onc section) to indicote thc loc
Use the CENTER SQUARE{ the well, if possiblc.
iions.
otion o
NORTH
I
*
=F
I
I
E
+
wATER EQUIVALENTS IABLE (Rounded Figures)
An ocre-foot covers I ocre o{ lond 1 foot deep.
I cubic {oot per second (cfs) . . 449 gollons per minure (gpm).
I ocre-foot . , 43,560 cubic feet . 325,900 gollons.
'1,000 gpm pumped continuously for one dcy produces 4.42 ocre.{eel
)00 gpm pumped continrrously for one yeor produces 160 acre-feet.
(IVI{ITE AND FINK COFY TO BE FILED WITH THE STATE ENGINEER
PINK COPY WILL BE RETURNED TO OWNER)
SE
+
NOR
+
ION LI E
t
{fn
UImn
+LLI
--.1zO
r-z
rn+
U
UJ
tJ)
+
sEcsou
++
ION LI E
+
SCALE OF T
1 M
E DIAGRAM I
I-r
ile -*-}
T\{O INCHES E
!-r +
UALS ONE.MI
l-t
TYPE..OR.
Pft INI IN
COP Y OF
BL ACK I'!K,
ACC EP TgO
wFJ.25-75
STATEiIENT MAILED
ON REQUEsT.
IHE AFFIANT(SI
who se moil ing
oddres s i s
CIl
COIORADO DIVISION OF WATER RE5OURCES
818 Centennicl Bldg., l313 Shermon St,
Denvet, Colorqdo 80203
RECEIVED
MAR 0 4 rge
tlftn 8E5o\JREEI
STATE OF COLORADO rirtprvtr sAtEdffrnrg
ss.
COUNTY OF
___' STATEMENT OF BENEFICIAL USE OF GROUND WATER
LATE REGISTRATION
v
PERMIT NUMBER tel 3CIO LOCATlON OF WELL
R.+p trrE tD
4 Na o{,he rfE Z,5ect,o,' /O -
Co!nly
c,v,
,,,r.KLFIE ,_:g_ -,Xlbsp_ ,*o _A - E .R^,_?L__ il., L,u-_-*iir,,t rNorsr rEorwi
berng duly sworn upon coth, deposes ond soys lhot he {rhey) is (ore) rhe owner(s)of the well described hereon, ihe well ;s
seciion line ond l4A7 feet from rhelocoted os described obove, ol distonces of ?ae 4 reer from tn" i9^tl4*(!SRrr' (!e ro$t!i
€ nSf ,sect on Iine; woler from this wefl wos firsl opplied to o beneficiol use {or the purpose( s) described hcre n orr th. /-f
doy o{Feg , WtZthe moximum sustoined pumping rote ol the wel t;, /O t gollons per minure, rhe punrprng
rore cloimed hereby it , -lO t - gollons per minufe; the totol deprh ol the well it l4 p -*feet; the dveroge onnuol omourrr
of worer to be diverte d,, I y+--- ocre-[eer; for which cloim is hereby mode {or CIO-AE-|T/t-
purpose(s); the legol descripiion o{ the lond on which the wqter from thrs well ls used is
sAt/€k Am 'JL o{ which
Il-. o"rus ore irrigcted ond which is illuslrqted on the mop on the reverge side of this form; thot this wetl wos compteted in
compiionce wiih the permit opproved ihere{or; this slotement cf beneficiql use of ground woter is filed in complionce wifh lqw; he
(they) hos (hove) reod the stolemenis mode hereon; knows the conlenl fhere.o{; ond thot the some ore true of his (their) knowledge.
ETE REVE oF Tr.ils F0RM)
Signoturel s)
Subscribed ond
fo belore me on
lrly Comrtr ission expires 4
0
ACCEPTED FOR FII-INC BY THE STATE ENGIN R OF COLORADO
PURSUAN] TO THE FOLLOW}NG CONDITIONS
E
'ii,i,?r4 o* "',wfu
nlffi.m,mnffifl ffiit sfltJdflffiH
MT FACCffi
sFp I 6 1983 d*
0a.rg
Dl,r.{S -. Bosi,, --*-* Mo' Dr:
FOR OFFICE U'E ONLY
Courr Cosc No
Di v.
Yi+ ll Us e
J
5e A
a,-}
Frror
'. .--_. ,,
Mo. Do" Y,
*E++P^,t+S&--Br'
V/clldrilled by
P crrnonent
Pump instolled by t{rf
))$zr<*
tt
79tLic. No.
Lic. No.
tl I
Mcter Scriol No {-l Flow Meter Dqre lnstolied
Owner of lond on which ETTF LLwoter ;s beir:g used
THE LOCATION OF T}IE WELL MUST BE SHO}IN AND FOR LARGE CAPACITY IRRIGATI
AREA ON WHICT{ TT{E WATER 15 USED MUST BF SHADED OR CROSS.I{ATCHED T}N THE DI
This diogrom represents.nine (9) sections. Use the CENTER SQUARE
(one-section) to indicote thc locstion o{ the well, if possiblc.
NORTH
WATER EQUIVALEi-lTS TABLE ( Rounded f,igure s)
An ocre-{oo1 corers I ocre o{ lond I foot deep.
i cubic loot per second icfs). . , 449 golions per rninufe {gprn),
locre-{oot ..43,560 cubic {eet . n5,900 gollons.
1,000 gpm pvmped continuously for one doy praduces 4.42 ocre-feet
100 gpm punrped conlrnuously for one yeor produces .l60 ocre-leei.
(V'hIlTE AND PtNK COPY TO BE FTLED WIThi TTIE STATE ENGINEER
PIHK EOFY WILL BE RETURNED TO OWNER)
ON WELLS THE
AGRAM BELOV{.
Ig
E
IF
l
+
NOR ION L
+
+
{m
-J
m
f^)
J
()
u +
o
r
t-
,
U
tl-f
rr)
+
SECSOU
+
ION LI
IT
SCALE OF
IT
1 M
+
E DIAGRAM IS
ile ---+
TWO INCHES E
+
ALS ONE"MI
I-r
w.lR-26-77
THIS FORM
'fiTJ$T
8E SUBMITTED
Y'rtTHlfi 60 DAYS *F COMPLET,ON
OF THE WONK trE8CN}SED HENT.
Of*. TYPE 08 PNINT
'N
BLACK
INK.
l-W
COLOHAOO DIVISION OF WATER RE$OURCES
l3l3 Sherman $treet - Room 818
Denver, Colorado 80203
WELL COMPLETIOh' AND PUMP IilSTALLATIO'{ FEPORT
PEBIIJ|ITilUft'IBER I. TAOP
l
v'
Tffi
WELL GWNEF Rt cherd D.l{r{7* of the $e 7r ol Sec^1n
ADDRESS &tJ'le. CoLoredo r. , 5 ,. " "*S-*, R. ,9J .. . ,t{.d.*,t
OATE COMpLereO -- [JctsbFr-2irr * . 19 31 HOL€ OTAMET€8
*ELL Los -g:I/fn. trom n-- to " 4? tt.
6 .-- in. trsm lh? "-ta *l6Q-tr
ia. lrom to-- tt.
P"M
ORlLLlNc METHoD-,eAtan$**A't r./l,f'ri *
CASINC RECORD; Flain Crring
siad-:5./.S& kind l[sef* from *1 *. to -4.3 * ft.
Si:e & & kind fVC from , 12 to *lil0- tt.
Size. {r. &kind Pinn.--from*J4O*to 160*fr,
Perlorrnd Crdng
$ire &" & kind ..PVQ* . from .-1?9-". ro *llr0* ft.
Sire
--* & kind from .-*"...-* to ----..*- ft.
$ize -*-, & kind lrcm *- ro
-.*
lr.
GROUTING RTCORD
Materlal f,rlnn*nt
lntervals 0:l+3 FS.
Placemerrt Method 1{a nd
cRAvHt PACX: $ire **3lg:----
lntarval co-1 f1n
TEIIY AATA
DateTected ,fg"*
Statis Water Levsl Prior to Tert fr.
Type of Test Pump
Length of Test
Su*ained Yield {Metered}
From To Type snd Color of Material
Itllatsr
Loc.
6
2
$
0
Air ?6$t..1O* Gale/
U$ addition€]
o*
3
)
3
r.s
,+0
55
6?,
t"e$
L'U
lou 1?S
ngsossary to complets
TCTAt. BEPTH
fopsoll
$a.iraTsnate
Gravel. $ano
$anast6ne
Gravel. Sand
$haler'Ssc,l,
Sand
$hale
l&txtrre {
1'11.[k" ?lt,
Gr.
TYl.
I{lxture (
fn.
Final Pumping Water Level
PUMP INSTALLATION BEPOBT
Pump Make
Type
P*wered by HP -. **--*
Pump $erial No
Motor Serial No.
Dale lnstalleu
Pump lntake Depth
Flernarks
WELL TEST DATA VI'ITH PEffMAt{ENT PUMP
Static Water Level Prior to Test
Length of Test F{ours
GPMSustained yield t Meteredl * *--
-
Pumping Water Level
I#ATER
TAStE
\\
I
Date Tested ourg or
FiApRESStott
Remark*
CONTRACTORS STATEMENT
The undersigned, being duly
pump installation descritred
sath,and says that he is the *ontrac{or of the well or
that he the statement made hereon; knows the cant€nt
thereof, end that the same of his
$ignature
State of Colsrado, Countv o{'tf\Ja.a*
Lieense No.
SS
,$gl
m
Subscribed and sworn to betore rne this
My Commission expi
Notary
s$'."ufrs *&a
, ns.g,*:
FORM TO BE MAOE OUT lN OUAAfiUPLICATG: IUHITE FOfiM mult bi an sriginsl oopy on both gidoe and rQnod.
$rHlTE AND 6ESEN copir! ilust ba lilcd with thr $bti Enginacr, Ptt$l( COFY ir lor rhr Ownrr rnd YELLOW COPY ir tor thr O?illcr.
l
lWRJ-!.Rev.76
Application must
be complete where
applicable. Type orprint in BLACK
|NK No overstrikes
or oro$ures unless
initialed.
(1) APPLICAI\IT' mai ing address
NAME
STREET //o'7 l*l ^)
CITY ?
TELEPHONE NO./a.-1t- /;53
{2} LOCATION OF PROPOS,ED WELL
Countv
IVru '/, ol lhe SE 14. Section
COLORADO DIVISION OF WATER RESOUBCES
818 Gentelrnial 8tdg., 1313 Shsrmon St., Denvcr, Colorrdo 80203
PE,F M r r.3P?L TCATTO N. .FORry!
I ) A PEBMIT TO USE GROUND WATEF
(X} A PERMIT TO CONSTBUCT A WELL
FOR: (Xl A PERMTT TO INSTALL A PUMP
I I REPLACEMENT FOR NO( I OTHER
WATEB COURT CASE NO.-
FOF OFFICE US€ ONLY: DO NOT ITE IN
Receipt No.
Basin
/6Ab I
Dist.
RECEIVT,D
JUL t 0 tggt
r,p 6 $ , onn. 9L Ja], 6 tJ ,,r*
qd.
W
This well shall be used in such a way es to cause
no material iniury to existing water rights. The
issuance of the permit does not assure the applicant
thet no iniury witl occur to anoth€r vested water
right or preclude another owner of a vest€d water
right from seeking relief in a civil court action.
rFPnorHD Puasutxf ro ons Lgts, 87-92-60!
,t6l (b! {Ir) }s fm 0$tY wEtt 0}I A TRACf,
0F 35 ACM9 0n I08E rs--3-4.-
"tcREs
6 s. €'. I 3 t4) ,. b P. .1,(, -q
ltlBovuD soR D0ilusrrc ugu, :f,cluniltr tD
Innrcrrroil 0F r0r ovER osn rcm 0D mr!
clADE[S TTD X.AffiS.
AerLrcATroN.agPRovEq
PERMIT NUMBER 1219{t0
DATE ISSUED
10
rN,S)rE.Wl
{3} WATEB USE AND WELL DATA
Proposed maximum pumping rare {gpm)
Average annual amount of ground w.ter
to be approffiated (acre-feet)
Number of acres to be irrigated:
Proposed total depth (feetl
Aquifer ground w€t6r is to be obtained from
Gna,tr-l
Owner's well designation
GROUND WATEE TO BE USED FOR:
{ I HOUSEHOLD USE ONLY-no irrisation {0}{x DOTdESTIC (1} ( )TNDUSTRTAL {5)(X LIVESTOCK {2) ( } IRRIGATION (6}
I ) COMMEFCTAL (4) ( ) MUNTC|PAL {8}
{ } orHER ts}
DETAIL THE USE ON BACK IN (I1}
{4I DRILLER
/5
Name
Street /J 5O (a''. *b J?J
*wDA
City lo
8Y
Tolephone No lss--riel Lic. No.7t
t.D -3e COUNTY
1:++
I+-+--
I
INOnTHI
t- l-
t-l -
I
+-+-
(51 fHE LQCATION OF THE PROPOSED WELL and the area on
ohgram beio;.
Urc the CENTER SECTION {l section. 640 acres) for the well location.+-+*+-+--+--r-_-+-+*+
(6)
b
+ I 26'rr. rrom - *M*..J',,n.(north or s0uthl
lU t
rt. rrom €lsr
(9) FOB REPLACEMENT UE!LS sivedistance
and direction Irom old well and plans for plugging:..
N /O
+
1
l<.-.- 1 r\rLE,52so F€ur (atst or ri/r5ll sec, line
LOT-BLOCK
-FtLtNG
* _
suB0rvrsroN
{7)
LOAAIEB Owner:
No. of acres Will this be
the only wef{ on thfi tr6ct?
(81 P_RO?OglFp qASLNG PROGRAM
Plain Casing
'7" in. tro . O n. ,o 5O r.
._.--_._in. from
-{t.
to-ft.
Perfot'ated casing
i *in, from 5D*i . to So t.
in. from ft. to.- ft.
++++
I
IJ-++li
I
+
I
+
I
+
I
+
II
i
+
I+
I
+
+
-+*
+
+*
+
-+-*
+
I
+
I
I
I
+
II
+
--+-+*+-+-+-*+--F-
The scale of the diagram is 2 inches = 1 mile
Each small I
WATEf, EOUIVALENTS TABLE (Rounced Figutot)
An acrc-foot covsrs 1 acrs of land 1 loot deep
I cubic foot per lecond tcfsl . . .449gsllons per minute lgpm)
A feffiilv of 5 will require spproximatety t ac.r.foot of water per year.I acre.foot. . . 43,560cubic feot . . . 32s,9@ gsilons.
t,OOO 9Dm Dumped continuously to( one day iroduces 4.42 zce.test.
{10)
Owner{s}No. oi acres JT
Legal I o
(111 the use of ground water: Household ure and dome$tic wells must indicate type of disposal
ryrtem to (t
(l2l QftIEB WATEfI RIGH.TS used on this tadd, inc{uding wells. Give Hegistration and Water Court Case Numbers.
Type or right Used for Descripfion of land cn which used
(r3l rHE (S} STATE{S) THAT THE INFORMATI T FORTH HEREON IS
OF HIS KNOWLEDGE.TR
tcsNT(Sl ' .SIGNATURE
o
Use additional sheets of paper if more space is required.
tabulations below, amounts are stated to the nearett dollar
CONTINUATION SHEET AIA DOCUMENf G7O3 Services
a c D G
coST
oE5CRTPTiONOi WOn(
REVI5ED
{c+Dl
TOTAICOMPLETID %
lNvolctD
Plumbins,snowmeb Radient
Plumbing Rough in and Equipment lnstall
Plumbingfinure lnilall and Punch tkt
stom Drainag€
Storm Drains
Trench Drain Fixtures and Material!
Wet Well Pumping System
Gas
Gas Pipinq
Hydronic M€chanical
Hydronic Mechanical Syster' Roughrn and tquipmenl ln*all
Hydronic Mechanicil system 5t.rt Up, Commi$ioning atrd Punch Li*
Hydronic Control Valves and Actrato.s
Gmth€rmal Sysem
Geothermal Heat Pump System Rough-in and Equipment lnstall
Geothermal Heat Pump System 5tad Up, Commissioning and Punclr List
Geothermai Piping from Service tf,trance to Crawl 5pace Heat Pumps
Acoustic Pipe-wrap
Ailtomaii.\{;rcr l..l Der..rionSv(r.m
s2e,880
5tr,22o
ssi4,84s
$90,855
53s,000
9362,760
564,020
513,s00
s88,7@
s12,700
(11 q00
s46,7AO
573,300
536,e0
s79,2oO
s2e,880
S7t 22o
$o
573,S0
$36,e0
979,200
s51484s
$90,8s5
$3s.mo
S3Ez,78o
s64020
$13,soo
S8s,7oo
s12,700
411.qoo
s46,700
562,760
So
5O
55,1s
So
557,m0
9c
so
So
9o
So
So
$14i,505
Srz6,66s
so
S4m
s3,s60
515,870
9o
So
So
9o
so
So
S157,375
S126.66s
So
$8,2m
so
$o
$8,6s
So
s6?,w
o.o%
22.2'
0.0%
o.M
11.9%
o.o%
84.6%
30.6%
o.o%
o.o%
)4.y4
o.o%
o.o%
a.o%
o.o%
5221,680
57\,220
So
S64,610
s36,m
$12,200
$357,470
S90,8ss
S35,@o
5236,115
554020
s11s0
S88,7oo
512,7m
s11.9m
546,700
s6,320
So
So
5869
$o
$5,7@
So
S1s,738
so
so
5r2,661
So
5o
So
5o
So
15@O
Total contrad
chanae orders
sl,785,{O so Sr,786,{o s{3,0@ s19,670 5422,9s 23.T4 91,363,470 S42,a3
co#1
coh2
co#3
co#
cof5
Move Underground Plumbing at Primary \rying
ASI 08 lnt Spa Plumbin8 Updales
Oelete WH-3 waier heater at Kitchen
Add Green RoofDrains at Office Sl 11
Move sewage tjector Piplng
5700
510,$0
(S1,ml
S8,ffi
57m
9?m
t10,S0
{S1,ro)
S&8m
57m
l0
57m
57m
s7@
$o
$o
50
S7m
lao.ea
O.UA
O.UA
o.o%
100.e4
o.o%
So
S1q3m
(51,300
S8,8m
So
So
570
5o
So
So
570
So$t'ktu as.3r.arm s{.€3
Fitures & Accessries
So qr
15450
Total Conkact s312,000 s312,000 So So So o,o%s312,000 50
So So o.o%So So
so 6A fi b
TOTAI E2,@a-m 41q.tu q2.117-tuO 5424,35 20.M 91.693.270 542€3
mportant Not€sl
1) All Chonge Orders must be submitted in writing ond received by Modigdn + Compony priq to the 20th ol the month in order tc be inclu(ted in the some month's Pay App,
orelse will be tejected until the Chonge Orderhos been submifted to Modigon + Company ond opproved.
2)Thisspreadsheetisit)tendedtobeusecllorConhe.tcndApprovedChangeArdeBonly. AllT&MinvoicesthatarenolintendelltcbeContractChanEeArde$
must be invoiced scparctely nat oti this Schedule of Values.
APPLICATION NO: 10 - 420 Willougby Way
APPtIcATION DATE: 06/30/2025
PERIOD TO: June 2025
420