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i ,act, , COLORADO DIVIWN OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 Sher w St., Ste 821, Denver, CO 80203 <br />Mainw m,;, us <br />- <br />0wWw <br />mil <br />CORRWC*M O# THE *tiLL'i ___ -TiON <br />ftt.;t% instructions on the revtnw sidt prior to compietiez the form. <br />N�rtte. Address and Person c1mmitw owrtB%hp of the weljHermit <br />Name(s) c=iJ!^RG�+ FUELS ia11 =rJG <br />Mailing Address _f_Q_C3fX_-t_ <br />For Office Use Onl} <br />RECE/V'EC <br />FE8112015 <br />VS ATr F Sau4C <br />COLOrr'ZSPFS <br />City St Zip t L&Rg.1dCF--t-- <br />G'CC>a iC rr1CLt�sCOfY] <br />Phone _ 711 -26% &-A$ Email Addrgr�;This form Is tiled by** nbriiad individuallentity (Calming that" are the owner of" well permit as referenced below This fi+ng is made <br />_ursuant to C,R_S. 37 -90 -143.. -- <br />WELL LOCATION well Permit NurTiber =q q T Eg-- <br />County , $EMQf.IT -�-_-- -- - ---_ _ _-- _ -- - _ - Well Name or # (optional) Myr-&S T_ -- <br />(Addressi (City) (State) (Zip) <br />Nor 1/4 of the 5W- 114 Sec- 2- 4 . Twp.20__ . N, of X S Range M -_ © E. orOW -�� -__ P bi <br />Distance frorrl Section Lures 5— __ Ft. From ' N o•X S D;Z --_. Ft From Q E or® W Line <br />OR GPS wel location informabon in UTM format You must cheek GPS unit for required settings as follows <br />Format must be UTM, r- zone 12 or zone 13 Units must be meters Datum must be NAD83; Unit must be set to true north <br />Easting <br />Northing _ <br />Subdivision Name -_-__-- -_-- ------_--_----------- ------ --- ---- t-ot Block ---- Filing/Unit - - - <br />The above listed Owner(S) says) that he, she ithey) own the well permit described herein The existing record is beteg amended for the <br />followirig reasons <br />JK change in name of owner ❑ Change M mailing address [j Correction of location for exempt wells permitted prior to May 8, 1972 and <br />rion-exempt weds permitted before May 17 1965. <br />Please see the reverse side for further tnformattort; eepaRitng correction of the well locatwn_ --- <br />-- - — --- - -- - <br />I (we) dein turd My #Mt I (we) (am) (efe�tf,ta ohAaof ttt <br />ieris) of the well permit described above, know the contents e statements made herein <br />and sV 4owl 8e'_ -- - - --- - - -- b _-_ _ -- - - <br />s t ownerfsl If sipnmovirtt nam & We Date (rnRAkywW) <br />2f; GS C4WSTSLLAT(0.J CQi <br />c�iewno SPELO", CO 5 -in" _ <br />it is time responsibility of the new owner of this well permit to complete andior smgn this f If an agent is signing or entering information <br />Please send confirmation of acceptance of change in owner nanme/address via Email address fisted above US Mail <br />- --------- --------- --- -- - - - - <br />As 4 <br />A 11 NC A <br />State Engineer t3v Date <br />TR43 2.04.7-14b Revised 8/25/15 <br />