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COLORADO DIVISION OF WATER RESOURCES For Office Use Only <br /> Form No. DEPARTMENT OF NATURAL RESOURCES <br /> GWS-11 1313 Sherman St., Ste 821, Denver CO 80203 <br /> 08/2016 (303)866-3581 <br /> CHANGE IN OWNER NAME/MAILING ADDRESS <br /> PRIOR TO COMPLETING THIS FORM,SEE INSTRUCTIONS ON REVERSE SIDE <br /> INCOMPLETE,POOR QUALITY,OR ILLEGIBLE FORMS CANNOT BE PROCESSED AND WILL BE RETURNED <br /> Name,address and phone number of person claiming ownership of the well permit: <br /> Name(s): Frances Barnett Lewis Trust <br /> Mailing Address: 608 North Vernal Avenue <br /> City,St.Zip: Vernal, UT, 84078 <br /> Phone: (970 ) 629 _5677 Email: fmbllewis@yahoo.com <br /> Well Permit Number:126165 Receipt Number: / '"i 'F 5 11 Case Number(optional): <br /> WELL LOCATION: County: Moffatt Weil Name or#(optional): <br /> Street Address at Well Location City State Zip <br /> 0 Check if well address is same as owner's mailing address <br /> SE 1/4 of the NE 1/4, Sec. 35 Township 4.0 0 N.or❑S., Range 101.0 0 E.or W., 6th P.M. <br /> Distance from Section Lines: 1;-950 it <br /> rVfrom E3 N.or❑S. Line, 1 -16_ Ft.from Q E.or❑W.Line. <br /> Subdivision Name(if applicable): Skull Creek#2 ,Lot 50 , Block , Filing/Unit <br /> NOTE: If changing/correcting the permitted location of a well,use Form No GWS-42. <br /> I(we)claim and say that I am(we are)the owner(s)of the well permit described above,know the contents of the statements made herein, <br /> and state that they are true to my(our)knowledge This filing is made pursuant to C.R.S.37-90-143. <br /> Signature(s)of the New Owner Please print the Signer's Name&Title Date <br /> • <br /> �t y V /( > ry> ,(. 1 j <br /> ..- � ,. �"„�l.•l 1�-�-t.�.,,1..1.�t�f,•4 _..r S �.": i '1.�,.ye� • Tyr - `>c' '?f: f /�ti;�,,',< t All. [`' <br /> It is the responsibility of the new owner of this well permit to complete and sign this form. If an agent is signing or entering information,please <br /> see instructions. <br /> Please allow 4 to 6 weeks for processing of this form. Thereafter,you can view or print the accepted document at: <br /> Signature of DWR staff indicates acceptance as a Change in Owner Name and/or Mailing Address. <br /> For Staff Use Only <br /> -- <br /> Staff Signature Date <br />