2015-08-31_PERMIT FILE - C1981012 ‎(2)‎

• Permit No: C1981012
• IBM Index Class Name: Permit File
• Doc Date: 8/31/2015
• Section_Exhibit Name: EXHIBIT 11 WATER WELL INFO PART 3
• Media Type: D
• Archive: No

I,VLVKAUU UIVIJIVIV.UF WAiEK KtJUUKI.tS
THIS iORM MUST BE
SUBMITTED PRIOR TO 101 Columbine Bldg., 1845 Sherman St. ~ ,
THE El(PIRATION OF THE Denver, Colorado 80203 `~
PERYR TYPE OR
PRINT IN BUCK iNK. - '.`~v
STATEMENT OF BENEFICIAL USE OF GROUND WATER -'
AMENDMENT OF EXISTING RECORD .>:• •~= -
.::.:i.
PERMIT NUMBER_~p-~-f¢--~
STATE OF COLORADO l
COUNTY OF L d 5 }SS.
~?. ! X71 B ~S JJ
THE AFFIANT(S) / ` G 7' ») / ~ ~, ~17a ~///
whose address
being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon; the well is
located in the ~ w 1/q of the_1L~1/a of Section ~~~ ,Township ~ ~ ~,
~~~~++ ~~~~JJ (N. or 5.1
Range~/~'G S ~ r° rti P.M. at distances of DSO feet from the /yer~~l section line
(E. Or W.) (North Or south)
and~f 9~J feet from the ~ ~ S~ section line; the total depth of the well is~feet; water from this well
(Est Rr west) '
was first applied to a beneficial use for the purpose(s) described herein on the~_day of ~ Z' 19.~:
thR maximum sustained pumping rate of the well is_~_gallons per minute, the pumping rate claimed hereby is~
gallons per minute; the ave//rage annual amount of water to be diverted is_~_acre~feet: for which claim is hereby
for_ oy e C h ~ J 2c (S F__ Q 71 T~rj purpose(s); the legal description of the land) on which the water
from this well is to be used is .~ o J'' S ~,Jo c A / ~~ja)) f, J(,u rZ~~ ~ 'P a O o 2u e 5
which totals • ~ a ~ acres and which is illustrated on the map on the revarse 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.
Ibed an~~~brn to before me on this T y
~.. Pfy~ mission expaes: a'`~
'Y '. a.+u ': .
.~ fit''. ` ~ yt/ ~ C ~G1r
F1
4 L + ~' Notary Public
ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF
COLORADO ON THIS DAY OF
19_.
s NGINEER
FOR OFFICE USE ONLY
Prior. Date, 19_
Well Use

T. _ _, R. _ _. P.M.
YieIC W.D ~ _ /~
co. t~ ~~
WHITE COPY FOR DIVISION OF WATER RESOV RCEs
PINK COPY FOR WELL OWNER