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<br />Dec-10-9~ 12:29P IDEAL VALLEY REALTY LTD <br /> <br />719 462 5755 <br /> <br />P.06 <br /> <br />StateJaesat of Verification and Membership Agreement <br /> <br />E.-1<:h participant in the AGtiA plan agrees to Indenm~"" defend. and hold h:umless the Arkansas OIOWldw:uer <br />Users" Assoc:Ulion from any and aU liability c:ocpenses. cl::ums. or 3ctiOns b:1Sed on that participanCs weJl <br />c1ivemons, <br /> <br />I certifY we the foregoin; information is true ~nd corteCt to the best of my knowled;e. I hcrebr ~utborize the <br />power supplier for e.1Ch welJ Included on this fonn 10 pt'O'ide power records 10 the Division Engineer and AQUA <br />on a monthly basis 3Ild (0 provide power meter and oIber inform:llion ;:J~ut my elearic::ll service iIS requested by <br />the Division Engineer, <br /> <br />I undemand mat :lloan has bec:n secured from the Colorado Water Conservation Board omd an account bas been <br />estIbIishCtt for repayment. Under the stille SlaEUte cn::lOnl the loan 3CCOunt. well users who acc:epl die beDCtilS of <br />the loaa must apee to ccue pumpinl should they f:ill to pay memberslUp dues. includinl tr.Ucr :L~enlS. I <br />Ilndemimci that ~ vinue of ~ membership in AQUA. I have accepted the benefits ollbis loan account. I hereby <br />lIp1:C 10 c=se pumpinl water covered by my mCUlbership immediately. if I fail to make full JIlYIDenl of my <br />membership dues or water fees. I 1.U1dc:ma.nd that failwe to cease pumping under these cin:umsranca; may result <br />in promlX :met coDll'le!e c:wwlmet1t by the Stale Engineer of the use of my well(s). I ~ agree to comply with <br />any new rules or amendmems to e.'Cisting rules adapl:ed ~ the SlOne Engineer and approved ~ the water coun <br />pertaininl to the measurement or use of groundwater OD the Arkansas River Basin. I have read the foregoing and <br />agree TO abide by its lenDs am1 all other re:1SOnable rules and regulations of AQlJ A.. <br /> <br />SignatUlC of Owner <br /> <br />Date <br /> <br />Calculation of 1998 Dues (Must be received. Dot later th8J1 <br />J&Il1l&ry 1S, 1998) <br />Administration No. of wells @ 5247 each <br />New Member ~o. of wells @. SZ5 each <br />Well Testing (For wells that must be tested in 1998) <br />Basic Test. No. ofweils @ $ 110 each Totai: <br />Complex Test. No. oiweils _@ S13S each Totai; <br />Please call Lbe ollie:: for well lest credit ~OUDt of payments already made. <br />Supplemental Plan (oniy for wells applying AFTER January 15) <br />~o. of wells r7JJ. $100 each <br />,- <br />Supplemental Plan (only for wells appiying AFTER February 15) <br />~o. ofweHs @ $300 each <br />Inactive Wells No. of wells rw. $ 60 each <br />'- <br />Total 1)118 to!" 1998 <br /> <br />T Ota!; <br />Total: <br /> <br />Total: <br /> <br />Total: <br />Totai: <br />Gr&lld Total: <br /> <br />CalnJadOD of aca-lellt ofW.~e:r Needed. to be allpDoated. for 1998 Pampmc <br />Seuoa (April I" to Much 31-C). W. caDDat pIVceu 1011r appilcation without th.W <br />!afonaado.. A biD for )'aU ....I:.r Will be sent aaer :receivtD.c the fo1knl1D&: <br />lafoftlladoa aad. wd1 he d.e DO Ia~ thaa Much 15, 1998. For &II id_ of.hat to <br />OI'd.er, a copy 01 laM: years U8e alaould. Jaa.. bee:a. wttb. thia application. <br /> <br /># l)F WELLS ACRES nw. "':R0P <br /> <br />I ACru: nXI' NEEDED FROM 111[ WD.LS <br /> <br />If you are a new active member. with this application,. please send copies of your: <br />Well test(s) (State 3.1 or 3.2 fonnls)). Past electric records or the State 6.: <br />Form(s) or Flow meter readings or the State 6.1 Fonn(.s) <br />Pa. 4 or 4 $"'" '"IX. 13......, <br />