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COLORADO DIVISION OF WATER RESOURCES <br />For Office Use Only <br />Form No. <br />DEPARTMENT OF NATURAL RESOURCES <br />Received <br />GWS-11 <br />1313 Sherman St., Ste 821, Denver CO 80203 <br />October 1, 2020 <br />08/2016 <br />(303) 866-3581 <br />dwrpermitsonline0state.co.us <br />CHANGE IN OWNER NAME/MAILING ADDRESS <br />PRIOR TO COMPLETING THS FORM, SEE INSTRUCTIONS ON REVERSE SIDE <br />INCOMPLETE, POOR OUALITY, 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): ARC Colorado. LLC <br />Mailing Address: P.O. Box 1169 <br />City, St. Zip: Pikeville KY 41502-1169 <br />Phone: ( 606 ) 444 - 7300 Email: rboone@appresourceco.com <br />Well Permit Number: Receipt Number: 3649693A Case Number (optional): <br />WELL LOCATION: County: Mesa Well Name or # (optional): RW-1 <br />1175 15 RD Fruita CO 81524 <br />Street Address at Well Location City State Zip <br />❑ Check if well address is same as owner's mailing address <br />SW 1/4 of the SW 1/4, Sec. 2 , Township 1.0 Q N. or[-] S., Range 3.0 ❑ E. or [E W., Ute P.M. <br />Distance from Section Lines: 505 Ft. from ❑ N. or Q S. Line, 1270 Ft. from ❑ E. or Q W. Line. <br />Subdivision Name (if applicable): , Lot . 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 />Signatures) of the New Owner <br />Please print the Signer's Name & Title <br />Date <br />Richard Boone, President <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 />https:Nwww.dwr state.co.us/Tools/WellPermits <br />Signature of DWR staff indicates acceptance as a Change in Owner Name and/or Mailing Address. <br />For Staff Use Only <br />Alex Teitz 1012/20 <br />_ <br />Staff Signature Date <br />