C04g Attachment 7 Well Permit Number 117217 1240LT26Q0107.pdf

WRy25 -75

TYPE OR

PRINT IN BLACK INK.

COPY OF ACCEPTED

STATEMENT MAILED

ON REQUEST.

i

Mr® Mawvols

S2A6'

PERMIT NUMBER _

UNITED STATES OF AMERICA, USDA

THE AFFIANT( S) Forest Service By: Lela K. Chavez whose mailing address is 11177 West 8th. Ave. P. O. Box 25127

COLORADO DIVISION OF WATER RESOURCES

818 Centennial Bldg., 1313 Sherman St.

Denver, Colorado 80203

STATE OF COLORADO

COUNTY OF Pueblo

SS.

STATEMENT OF BENEFICIAL USE OF GROUND WATER

XX AMENDMENT OF EXISTING RECORD

LATE REGISTRATION

117217

County

AFFIDAVIT

LOCATION OF WELL

Lake

SE h of the NE Y., Sectia' 9

City Lakewood Colorado _ 80225 T„,. 10 S I Rn,, _$ Q__ W 6 P N she is an employee of the Depaitthdtit of A& 16ulture, Forest Service; "and that the it* is being duly sworn upon oath, deposes and says thatx1} g7rg the owner( ok of the well described hereon; the well is located as described above, at distances of 2100 feet from the ttorxh section line and 1060 feet from the a » T. an ,. IT. I east section line; water from this well was first applied to a beneficial use for the purpose( s) described herein on the 26 ii." ON , s " i day of November , 1981_; the maximum sustained pumping rate of the well is 8 _ gallons per minute, the pumping rate claimed hereby is - 8 gallons per minute; the total depth of the well is 184 feet, the average annual amount of water to be diverted is 1. 0 acre -feet; for which claim is hereby made for domegtir and adminigtrativPs, purpose( s); the legal description of the land on which the water from this well is used is the same as stated above of which acres are irrigated and which is illustrated on the map on the reverse side of this form; that this well was completed in compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he they) has ( have) read the statements made hereon; knows the content thereof; and that the same are true of his ( their) knowledge.

COMPLETE REVERSE SIDE OF THIS FORM)

S i gnat ure( s)

Subscribed and sworn to before me on this 1""106 day of 19

My Commission expires:

NO TAR . F' Is L c

ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO

PURSUANT TO THE FOLLOWING CONDITIONS:

ACCEPTED TO CORREC THE DIRECTION OF

1060 SOUTH TO y

1060 EAST ONLY. 5- II`

FOR OFFICE USE ONLY

Court Case No

Prim. _ Mo. Day _— _ Yr.

Di.. Cty.

S. _ _ /., 7., ' R.

Well Use

Dist. _ Bosin Man D,, MAR 1 1 1988 V - .

d', t'. h DATE ATE GINEER ' By

Well drilled by Shelton Drilling Co.

Permanent

Pump installed by U. S. Forest Service

Meter Serial No.

Owner of land on which water is being used _

Flow Meter Date Installed

United States of America

Lic. No.

Lic. No.

THE LOCATION OF THE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS THE AREA ON WHICH THE WATER IS USED MUST BE SHADED OR CROSSHATCHED ON THE DIAGRAM BELOW.

NORTH

This diagram represents nine ( 9) sections. Use the CENTER SQUARE one section) to indicate the location of the well, if possible.

WATER EQUIVALENTS TABLE ( Rounded Figures)

An acre - foot covers 1 acre of land 1 foot deep.

1 cubic foot per second ( cfs) ... 449 gallons per minute ( gpm).

1 acre - foot ... 43, 560 cubic feet .. 325, 900 gallons.

1, 000 gpm pumped continuously for one day produces 4. 42 acre - feet.

100 gpm pumped continuously for one year produces 160 acre - feet.

WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER

PINK COPY WILL BE RETURNED TO OWNER)

I

C_ G

TOM

NORTH SECTION LINE

w

NM

t

X J zo o Z_ Uw w

SOUTH SEC1 ION LI E

T E SCALE OFT E DIAGRAM IS TWO INCHES E UALS ONE -MI E

1 Mile

WATER EQUIVALENTS TABLE ( Rounded Figures)

An acre - foot covers 1 acre of land 1 foot deep.

1 cubic foot per second ( cfs) ... 449 gallons per minute ( gpm).

1 acre - foot ... 43, 560 cubic feet .. 325, 900 gallons.

1, 000 gpm pumped continuously for one day produces 4. 42 acre - feet.

100 gpm pumped continuously for one year produces 160 acre - feet.

WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER

PINK COPY WILL BE RETURNED TO OWNER)

I

C_ G

TOM

TYPE OR

PRINT IN BLACK INK.

COPY OF ACCEPTED

STATEMENT MAILED

ON REQUEST.

THE AFFIANT( S)

COLORADO DIVISION OF WATER RESOURCES

818 Centennial Bldg., 1313 Sherman St.

Denver. Colorado 80203

STATE OF COLORADO

COUNTY OF

Lake

SS —

AFFIDAVIT

2.

un . , AWL -era.

X STATEMENT OF BENEFICIAL USE OF GROUND WATER

AMENDMENT OF EXISTING RECORD

LATE REGISTRATION

PERMIT NUMBER

U. S. D. A. Forest Service whose mailing address is 11177 West 8th Ave. P. O. Box 25127

LOCATION OF WELL

Lake Coun1Y

SE

n of h.

NE 9

I z, s.< rGn

City Lakewood CO 80225 Twp 10 S prig _ 80 W 6 P M being duly sworn upon oath, deposes and says that he ( they) is ( ore) the owner( s) of the well described hereon; the well is located as described above, at distances of _ 2100_ feet from the North section line and 1060 _ feet from the o., r onin o. e, - 1

South x section line; water from this well was first applied to a beneficial use for the purposes) described herein on the 26th a.]. a. w.], 1 day of November 1 19, 81 ; the maximum sustained pumping rate of the well is 8 gallons per minute, the pumping rate claimed hereby is _ of water to be diverted is t_ n gallons per minute; the total depth of the well is feet; the average annual amount acre -feet; for which claim is hereby made for domestic and administrative purpose( s); the legal description of the land on which the water from this well is used Is the same as that stated above _ of which

0 acres are irrigated and which is illustrated on the map on the reverse side of this form; that this well was completed in compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he they) has ( have) read the statements made hereon; knows the content thereof; and that the some are true of his ( their) knowledge.

COMPLETE REVERSE SIDE OF THIS FORM)

Signat ure( s)

Subscribed and sworn,, to before me on this 4LL day of \ 7. 19

My Commission

111. 11

ACCEPTED FO

PURSUANT TO IIIL I VLLV. IILV 1., 111. 11., 111.

FOR OFFICE USE ONLY

Coors C. ze No

PNOr. Me Day Y

Div. 02 0,. 73

S. c. --- 7.. — Y.. ' A.

Well U.

Basin Man. D]

3 1984

C y

JAN A ststant _

DATE STATE ENGINEER BY

Well drilled by Shelton Drilling Company Lic, No

Permanent

Pump installed by Lic No

Meter Serial No. Flow Meter Date Installed

Owner of land on which water is being used __ U. S. Forest Service

THE LOCATION OF THE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS THE AREA ON WHICH THE WATER IS USED MUST BE SHADED OR CROSS- HATCHED ON THE DIAGRAM BELOW.

NORTH

This diagram represents nine ( 9) sections. Use the CENTER SQUARE one section) to indicate the location of the well, if possible.

WATER EQUIVALENTS TABLE ( Rounded F) gures)

An acre - foot covers 1 acre of land 1 foot deep.

1 cubic foot per second ( cfs) . . . 449 gallons per minute ( gpm).

1 acre - foot . .. 43, 560 cubic feet . 325, 900 gallons.

1, 000 gpm pumped continuously for one day produces 4. 42 acre - feet.

100 gpm pumped continuously for one year produces 160 acre - feet.

WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER

PINK COPY WILL BE RETURNED TO OWNER)

S i r

S

NORTH SECTION LIINE

fM w +

J

M

Z0 O V m w

SOUTH SECI ION LINE

T E SCALE OFT E DIAGRAM IS TWO INCHES E UALS ONE- MIL E

1 Mile-_

WATER EQUIVALENTS TABLE ( Rounded F) gures)

An acre - foot covers 1 acre of land 1 foot deep.

1 cubic foot per second ( cfs) . . . 449 gallons per minute ( gpm).

1 acre - foot . .. 43, 560 cubic feet . 325, 900 gallons.

1, 000 gpm pumped continuously for one day produces 4. 42 acre - feet.

100 gpm pumped continuously for one year produces 160 acre - feet.

WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER

PINK COPY WILL BE RETURNED TO OWNER)

S i r

S

W R - zs.»

RECEIVED

COLORADO DIVISION OF WATER RESOURCES

THIS FORM MUST BE SUBMITTED 1313 Sherman Street - Room 818 DEC 3 0 1983WITHIN 60 DAYS OF COMPLETION Denver, Colorado 80203

OF THE WORK DESCRIBED HERE -

WATER RFSOl1RCF$ ON. TYPE OR PRINT IN BLACK WELL COMPLETION AND PUMP INSTALLATION REPORT STATE - EN ouRcE

INK'

PERMIT NUMBER 117217 OOID.

WELL OWNER USDA FOREST SERVICE _ Se '/. of the Ne % of Sec. 9

11177 West 8th Ave.

ADDRESS Lakewood- Co. 8022r T. — 10 3 R. _ 80 W 6th P. M.

DATE COMPLETED Nov 30 119- 820 HOLE DIAMETER 0 24

WELL LOG

in. from to ft.

Water 6112 24 160

in. from to ft. From To Type and Color of Material Loc.

0 160 in 120

TOTAL DEPTH - 160

Use additional pages necessary to complete log.

in. from to ft.

DRILLING METHOD Rot " T CASING RECORD: Plain Casing

Size — 7 & kind 17# from 0 to 24 ft.

Size & kind from to ft.

Size & kind from to ft.

Size 5 94kind

Size kind

Size kind

GROUTING RECORD

Material Cement

Perforated Casing 188 from 20 from — from

Intervals 10 - 20

Placement Method Gravi

GRAVEL PACK: Size

Interval to 160 ft.

to ft.

to ft.

TEST DATA

Date Tested Nov. 30 19 80

Static Water Level Prior to Test 120 ft.

Type of Test Pump air

Length of Test 112 hr.

Sustained Yield ( Metered) 10 gm

Final Pumping Water Level total

PUMP INSTALLATION REPORT, _

Pump Make

Type

Powered by —

Pump Serial No

Motor Serial No

Date Installeo

Pump Intake Depth

Remarks

HP

WELL TEST DATA WITH PERMANENT PUMP

Date Tested

Static Water Level Prior to Test

Length of Test _.__ _ Hours

Sustained yield ( Metered)— GPM

Pumping Water Level

Remarks

CONTRACTORSSTATEMENT

The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or pump installation described on; that he has read the statement made hereon; knows the content thereof. and that the sayrls true of his-awa- knewledae /

Signature U License No. Ze'l

State of Colorad= Cou/nty , SS

Subscribed and sworn to betore m 19.

My Commission expires: / Z y19-

Notary Public

FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed.

WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Driller.

4.1 - 5 -74 COLORADO DIVISION OF WATER RESOURCES

117217

101 Columbine Bldg., 1845 Sharman Si., Denver, Colorado

PERMIT APPLICATION FORM '

Application must be complete where A PERMIT TO USE GROUNDWATER applicable. Type or X) A PERMIT TO CONSTRUCT A WELL print in BLACK FOR: ( ) A PERMIT TO INSTALL A PUMP I

I N K. No overstri kes or erasures unless 1 REPLACEMENT FOR NO.

initialed.

OTHER

1) APPLICANT- mailing address

NAME

IISOA, Forest Service

STREET 11177 West 5th Ave., P. O. Box 25127

CITY Lakewood Colorado 80225 State) ( Zip)

TELEPHONE NO. 234 - 5570

2) LOCATION OF PROPOSED WELL

SAN ISABEL NF - Leadville RD

County Lake

SE y. of the NE / Section9

Twp. 10 --$-, Frig. _ 80 mod_, 6 th P

3) WATER USE AND WELL DATA

Proposed maximum pumping rate ( gpm) 15

Average annual amount of ground water to be appropriated ( acre - feet): 7 - 9

Number of acres to be irrigated:

Proposed total depth ( feet) 100

Aquifer ground water is to be obtained from:

Owner' s well designation Crystal

Elttaekes well

GROUNDWATER TO ( Ell? DRFOk

HOUSEHOLD USE ONLY - no irrigation ( 0)

X) DOMESTIC ( 1) ( ) INDUSTRIAL ( 5)

1 LIVESTOCK ( 2) ( ) IRRIGATION ( 6)

COMMERCIAL ( 4) ( ) MUNICIPAL ( 8)

OTHER ( 9)

4) DRILLER

Name I; i-eeased - pentrmat —te ho 1- 4-

Street

City State) ( Zip)

Sheet 1 of 2

RECEIVED

OCT 3 1 1980

NATXR II

GKTE ENGINEEA

COLA

FOR OFFICE} USE ONLY: DO NOT WRITE IN THIS COLUMN

06009Receipt No. J611116 /

Basin Dist, CONDITIONS OF APPROVAL

This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of the 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.

APPROVED PURSUANT TO CRS 1973, 37 - 92 -602

3)( b)( II) AS THE ONLY WELL ON A TRACT

OF 35 ACRES OR MORE DESIGNATED AS 140

ACRES IN_ SEYv NE K/. tEC. 9 T JOS., F. Boa,., 6O.M.

APPROVED FOR DOMESTIC USE, INCLUDING THE

IRRIGATION OF NOT OVER ONE ACRE OF HOMB

GARDENS AND LAWNS.

THE MUNICIPAL OR COUNTY GOVERNMENT

SHALL BE CONSULTED WHEN LOCATING

THIS WELL, AND THEIR REGULATIONS

SHALL BE COMPLIED WITH.

APPLICATION APPROVED

PERMIT NUMBER

DATE ISSUED

117217

EXPIRAIAQN DATE

BY ' , / c.

Telephone No. Lic. No.

I. D. 2 COUNTY 373

5) THE LOCATION OF THE PROPOSED WELL and the area on which the water will be used must be indicated on the diagram below.

Use the CENTER SECTION ( 1 section, 640 acres) for the well location.

Ii` - - - - --

1 MILE, 5280 FEET — - -)

I I I I

NORTH SECTION LINE

I

4-

NORTH+

I z0 V w

I N 4- 3 fI 1I I

I

7- —

X

I

I I

1I I

I

7- — t

D

NHNM

J Oz r_

Zm +

U. Ill JC411UN LINC

I f-- -

The scale of the diagram is 2 inches = 1 mile

Each small square represents 40 acres.

WATER EQUIVALENTS TABLE ( Rounded Figures)

An acre -foot covers 1 acre of land 1 foot deep 1 cubic foot per second ( cfs) ... 449 gallons per minute Igpm)

A family of 5 will require approximately 1 acre -foot of water per year.

1 acre -foot ... 43,560 cubic feet ... 325,900 gallons.

1, 000 gpm pumped continuously' for one day produces 4. 42 acre -feet.

I

4-

6) THE WELL MUST BE LOCATED BELOW

by distances from section lines.

2IE)Eft. from sec. line h or South)

1060 ft. from east sec. line east or west)

LOT BLOCK - FILING*

SUBDIVISION

7) TRACT ON WHICH WELL WILL BE

LOCATED Owner: USDA, Forest Service

No. of acres 40 . Will this be the only well on this tract?

Yes

8) PROPOSED CASING PROGRAM

Plain Casing

R in. from 0 ft. to 60 ft.

in. from ft. to ft.

Perforated casing

6 _ in. from 60 ft. to 100 ft

in. from ft. to ft.

9) FOR REPLACEMENT WELLS givedistance and direction from old well and plans for plugging it:

10) LAND ON WHICH GROUND WATER WILL BE USED:

Owner( s):

USDA, Forest Service

I o,,,, ,,, ,; ,; SE4NE4, Section 9, T. 10 S., R. 80 W., 6th P. M.

No. of acres:

11) DETAILED DESCRIPTION of the use of ground water: Household use and domestic wells must indicate type of disposal system to be used.

The well wiII cprirp f-hp wnt-pr nppda of the Crystal Lake Workcenter. The center when completed will have aworkshop two bunkhouses for 16 people, and two residences the residences will have small yards. Septic systems with leach fields will serve the

12) OfAMMIR RIGHTS used on this land, including wells.

Type or right Used for (purpose) Description of land on which used

13) THE APPLICANT( S) STATE( S) THAT THE INFORMATION SET FORTH HEREON IS

TRUE TO THE BEST OF HIS KNOWLEDGE.

SIGNATURE OF APPL ICANT(S) - 7 11.

Use additional sheets of paper if more space is required.

RICHARD D. LAMM

Governor e ;.

N t •

1 76*

OFFICE OF THE STATE ENGINEER

DIVISION OF WATER RESOURCES

1313 Sherman Street -Room 818 Denver, Colorado 80203

303) 888 -3581

February 4, 1983

Shelton Drilling Company P. O. Box 1070

Basalt, CO 81621

RE: Well Permit No. 117217

Dear Mr. Shelton:

JERIS A. DANIELSON

Stale Engineer

This office has received information that you constructed a well under

Permit No. 117217 on or about November 1981. A copy of the subject permit is enclosed. Would you please check your records and file the completion report as required by the Rules and Regulations. Please reply, in writing, within 20 days of your receipt of this letter. If there is no response within this time, additional action will be initiated.

If there are any questions concerning this matter, please contact this office.

Sincerely, Richard A. Bell

Water Resources Engineer

Ground Water Section

RAB / SJ: ew

Enclosure

United States Forest Pike and San Isabel 1920 Valley Dr.

Department of Service National Forests Pueblo, CO

Agriculture Comanche and Cimarron 81008 -1797 National Grasslands

4h ER RG9OURM

AT,E ENGINEER

COLO.

Colorado Division of Water Resources

818 Centennial Bldg., 1313 Sherman St.

Denver, Colorado 80203

Dear Sir:

Reply to: 2540

Date: March 7, 1988

An amended copy of the Statement of Beneficial use for well # 117217 is enclosed. The amended copy corrects the location. The original Statement of

Beneficial Use put the location at 2100 feet from the north section line and

1060 feet from the s2mt,k section line. The enclosed Statement of Beneficial

Use amends the location to read 2100 feet from the north section line and 1060 feet from the east section line.

If you have any further questions concerning this matter, please contact Lee Chavez at ( 719) 545 - 8737.

Sincerely

Dickk Roth

Resource Staff Officer enclosure

Ike

SFO-6200•2e( 7. 02)