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Attachment 6a - Change in Owner 285910 <br /> COLORADO DIVISION OF WATER RESOURCES ± _ 1 nr Office Use Only <br /> Form No. DEPARTMENT OF NATURAL RESOURCES <br /> GWS-1 t 1313 She•mari St , Ste 821, Denver CO 80203 <br /> g8120liz, (3031866-3581 j <br /> d',,%rgerm;tsonllneCastateCO G+s _ <br /> CHANGE IN OWNER NAME/MAILING ADDRESS <br /> PRIOR TO COMPLETING THIS FORM,SEE INSTRUCTIONS ON REVERSE SIDE j <br /> INCOMPLETE,POOR QUALITY OR ILLEGIBLE FORMS CANNOT BE PROCESSED AND WILL BE RETURNED - V i,,TErt <br /> NV irie.address and phpn,V y;larmtng pwnersN of the}vel ,err iit t•w• <br /> ! Nan-eis) La Plata Co,,nty Lard LLC__� _ <br /> i <br /> Mailing Address 13742 W <br /> E <br /> City,St Zip- Arvada.CO LUWGn <br /> i Phone. 308 160 _8925 Emai Sara Glinatsts<sgllnatsis@diamondhdlfarrns,er3rn> ' <br /> Well Permit Number:1tSh910 __ Receipt Number'36505736 Case Number(optional);, <br /> 'NF_LL(.00AT.Q County t a Plata Well Name or#(opbnna,) May nay No 2- <br /> Street Address at Wic,tl Locat,on City T State Zip <br /> C3 Check if well address is same as owner's mailing address <br /> SW 114 of tie NE _ 1!4, Sec 28 Township 36 0 0 N,or❑S., Rar)ge 1 1.0 Q E ar©W , N.M P M _-- P M <br /> i Dtstafic:c-from Section Lines: .2100 Ft from Q N or 0 S Line, 2600 Ft from[]E.or Q W Line <br /> Subdivision Name(if applwaole),___---- Lot_._ .. Block__, Fi!ing/Un,t <br /> NCTE- It changingr`Correct;n-;the permIttec loalticr3 of a Well, use Form No.G'WS-42 <br /> I(we)c aim ar3(j say that I am(we<.,re)the owners)of;he welt permit Cescribed above,know the content%of the statements made herein <br /> anc state'hat!hey are true to my;our)knowiedge. This filing is made pursuant to C R.S.37-s0 143 <br /> S,g^ature(s4af the Ne, 07r i Please print the Signers Name&Title � Date <br /> I "=� Alt!-Lr -'1... �v t "�{) 1 ✓'l C l'�Gi! 6 <br /> j { <br /> I It is the resounsIbihry of ht'fji_w owner r)f this well permit to complete <atid-sign this fof m if an argent is srgntng or entering+nforrnation,please <br /> see 105trucUol7s <br /> Plt;ase allow 4 to 6 wee,cs for proces, of this form Th ci tnafter,yo 3 can view ui mtcn <br /> view(; pit at the accepted d :, t at, <br /> t11t,�);1W.V.!1'.^Jr state cr) <br /> Sign,aturc of tJWR staff ind,cates acceptance as a Criange in Owtier Naire and:of klai6ng Address <br /> For Staff Use Oily <br /> { <br />