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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 p <br /> 08/2016 (303)866-3581 I�ECEI Mt`'IEO <br /> dwr rmit online t . <br /> CHANGE IN OWNER NAMEIMAILING ADDRESS APR 2 4 2018 <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 WATER RESOURCES <br /> Name,address and phone number of person claiming ownership of the well permit: STATE ENGINEER Cf7La, <br /> Name(s): Precast Concepts LLC Go Ed Anderson <br /> Mailing Address: 4720 Bow Mar Drive <br /> City,St.Zip: Bow Mar,CO 80123 <br /> Phone: 3( 03 ) 210 - AS% Email:ed@spruceinvllc.com <br /> Well Permit Number:49434-F Receipt Number:424512 Case Number(optional): <br /> WELL LOCATION: County: Mesa Well Name or#(optional): <br /> 2311 River Road Grand Junction CO 81505 <br /> Street Address at Well Location City State Zip <br /> ❑Check if well address is same as owner's mailing address <br /> NW 1/4 of the SW 1/4,Sec. 5 ,Township 1.0 N.or S., Range 1.0 ❑E.or W., UTE P.M. <br /> Distance from Section Lines: 1700 Ft.from❑N.or S.Line, 200 Ft.from❑E.or 2 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 y(our)knowledge. This filing is made pursuant to C.R.S.37-90-143. <br /> Signature f the New Please print the Signer's Name&Title Date //0 <br /> 'Lo k0b?L-Se'--j pkzz/V bi�-� *Igor <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 /> hftp://www.dwr.state.co.usNVeliPermitSearch <br /> Signature of DWR staff indicates acceptance as a Change in Owner Name and/or Mailing Address. <br /> For Staff Use Only <br /> law h-yL0r <br /> Staff Srgfheve <br /> Date <br />