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!f <br /> i2e��•p� ��03236 Py ''j' .�`�t <br /> Form STATE OF COLORADO For Office:13.se Only <br /> No. OFFICE OF THE STATE ENGINEER <br /> GWS-42 1313 Sherman St., Ste 821, Denver CO 80203 <br /> 10/2011 Main: (303) 866-3581 Fax: (303)866-2223 <br /> AP__P__LI_CATION FOR ELL LOCATION AMENDMENT 'Au6 2 X 14 <br /> PRIOR TO COMPLETING THIS FORM,SEE INSTRUCTIONS ON REVERSE SIDE tFi<h i <br /> WELL OWNER: <br /> Name(s) Energy Fuels Resources (USA) Inc. <br /> Mailing Address 225 Union Blvd. Suite 600 <br /> Iz- <br /> City: Lakewood 80228 State: coCC Zip Code: CONT. MNGR. <br /> Phone: 303-974-2140 Div 7- WD Basin MD <br /> WELL LOCATION: Well Permit Number: 287946 Receipt Number: 9703236 <br /> County San Miguel Owner's Well Designation (optional) MW-TPZ1 <br /> (Address at well location) (City) (State) (Zip) <br /> SE 1/4 of the SE 1/4, Sec. 10 ,Township 44 ® N.or❑ S., Range 18 ❑ E. or®W., New Mexico P.M. <br /> Distance from Section Lines Ft. ❑ N.or❑S. Line, Ft. ❑ E. or❑W. Line. <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 689565 <br /> Was GPS unit checked for above items?❑YES❑ NO Northing 4217726 <br /> The location of the existing well needs to be amended for the following reason(s): Attach appropriate documentation as necessary. <br /> The original permit location's quarter, quarter section was incorrect. The well was intended to be drilled in the SE1/4 SE1/4 <br /> of Section 10 which is where it was drilled. <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). I (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 knowledc e. <br /> Signature o e I-owner or agent Please print the Signer's Name &Title Date <br /> V. P En v tv, MI-A Zol4- <br /> For Office Use Only <br /> Approved pursuant to Policy Memorandum 93-1 <br /> For an amended well location only as stated above <br /> W <br /> 8 z8 <br /> State Engineer By Date <br />