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wRJ-ssao STATE OF COLORADO <br /> Index No. S DIVISION OF WATER RESOURCE , 67 90 <br /> 7 0 <br /> q._ <br /> IDwD OFFICE OF THE STATE ENGINEER �` j�Y' <br /> Yield MAP AND STATEMENT FOR WATER WELL FILING RECEI`C,cD. <br /> Checked By 1►9ZIa 0s WATER•RESOURCES M <br /> PERMIT NUMBER ��� STATE Ef`lGIPIEER ��' <br /> STATE OF COLORADO ) SS WELL LOCATfO �`�Ii '�22ti g i <br /> La Pla to County <br /> CLAIMANT (s) Diana G. Lapp <br /> being duly sworn upon oath deposes and says that he (they) is (are) NE <br /> 1/4 of MIA '/, sec. <br /> the owner (s) of the well described hereon; the total number of acres <br /> T. 39N R. l?.LL�.-,-, NM, —P.M, <br /> of land irrigated from this well is �" <br /> work was commenced on this well by actual construction on the INDICATE WELL LOCATION ON DIAGRAM <br /> 30th NORTH <br /> day of Dctabor 19 71 ; the sustained <br /> yield from said well is---&'gpm;for which claim is hereby made i E <br /> for. �� J purpose (s}; T- --- <br /> _ - I I i <br /> the average annual amount to be diverted is _— n <br /> acre-feet; this map and statement is filed in compliance with law; I l I m <br /> he (they) has (have) read the statements made hereon; knows the I k <br /> content thereof; and that the same are true of his (their) own <br /> knowledge. l I I <br /> I l I <br /> I f I <br /> Signature (s) <br /> SOUTH <br /> Address: — - - <br /> 'el-I �. ,� WELL SHALL BE LOCATED WITH REFERENCE TO <br /> GOVERNMENT SURVEY CORNERS OR MONUMENTS, <br /> Subscribed and sworn to before me on this 21st day OR SECTION LINES BY DISTANCE AND BEARING. <br /> of December 19 71 200 ft. from South section line. <br /> (North or South) <br /> My Commission expires: . Apx l l 5w 1973 <br /> (Seal) p649 ft. from East section line. <br /> (East or West) <br /> Notary Public <br /> Ground Water Basin. <br /> Water Management <br /> WELL DATA District <br /> Date Completed November 9 1971 Domestic wells may be located by the following: <br /> Static Water Level_ Dry Hn]e _ LOT , BLOCK <br /> Total Depth of Well 00 <br /> r _ SUBDIVISION- <br /> FILING # <br /> ACCEPTED FOR FILING IN THE OFhCE OF THE STATE ENGINEER OF COLORADO ON THIS DAY <br /> OF — 19 <br /> STATE ENGINEER <br /> FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br /> WHITE AND GREEN copies must be filed with the State Engineer within 30 days after the well is completed or within 7 days <br /> after expiration date of the permit, whichever is sooner; PINK COPY is for the Owner and YELLOW COPY is for the Driller. <br />