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-a 1-7 <br />Form <br />STATE OF COLORADO <br />For Office Use Only <br />No. <br />OFFICE OF THE STATE ENGINEER <br />GWS -42 <br />1313 Sherman St., Ste 821, Denver CO 80203 <br />10/2011 <br />Main: (303) 866 -3581 Fax: (303) 866 -2223 <br />RECEIVED <br />urag, nCT 14 2014 <br />APPLICATION FOR WELL LOCATION AMENDMENT <br />PRIOR TO COMPLETING THIS FORM, SEE INSTRUCTIONS ON REVERSE SIDE <br />WELL OWNER: <br />Name(s) FNERGY FUELS C6*,L� X-4C_,. <br />�t8�`fit8 <br />RCg <br />�x3 8a48 � W�C�NEERS <br />WE <br />CONT. MNGR. <br />Div a WD /Z Basin MD <br />Mailing Address L30K 4 <br />PC C t <br />5 <br />City: A-0 CG' State: GU Zip Code:e i <br />Phone. 71 cl 7FV+ (c3q 5 <br />WELL LOCATION: Well Permit Number: 2 g 4 7 8 3 Receipt Number. -?2 G 5 1 B <br />County FRF-MotJ-7 Owner's Well Designation (optional) MW -23 <br />(Address at well location) (City) (State) (Zip) <br />_WE1/4 of the 5 ry 1/4, Sec. 19 , Township :20 ❑ N. or M S , Range 6q ❑ E. or tK W., 6TV P.M. <br />Distance from Section Lines , l v 2— Ft ❑ N. or CA S Line, :21! 1 Ft ❑ E. or M W. Line. <br />-- f — <br />Subdivision Name , Lot , Block , Filing /Unit <br />Optional: GPS well location information in UTM format. The following GPS settings are required <br />Format must be UTM. Units must be in meters. Datum must be NAD83 Unit must be set to true <br />north. ❑ Zone 12 or ❑ Zone 13 Easting <br />Was GPS unit checked for above items? ❑ YES ❑ NO Northing <br />The location of the existing well needs to be amended for the following reason(s): Attach appropriate documentation as necessary. <br />VJ416i l REC °��l�c�v � s �� tr�-�- 714 MOnl f ► aCZ WELL nLT (67-a9-20 /y) <br />ER(1,cW .DU S pt MEAITIO �Jls FRoM 7hg- IL /E S1 =.Crl & J LIMES WERE <br />t ti'i4PVl�R"rEN iLU F�1T�fZED� `i EtE C r�tZECT PtMCtJrtGAJS ARE -RED <br />The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor <br />pursuant to C.R.S. 24- 4- 104(13)(a). 1 (we) claim and say that I (we) (are) the owner(s) of the well described above, have read <br />the statements herein, know the contents thereof, and state that they are true tom our knowledge. <br />Signature(s) of the well owner or agent <br />Please print the Signer's Name & Title <br />Date <br />For Office Use Only <br />Approved pursuant to Policy Memorandum 93-1 for an amended well location only as stated awe. <br />I r�tlti�rtf4 }It � !b(a1i918 <br />�nta in /14t)014 1041 04 AM <br />Tran�acttoft Total %FJ000 <br />c;ItF('K.£t1747 3Fif) 00 <br />/0 rI�Zo1 � <br />State Engineer By Date <br />V v <br />