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MQR-RA-2RR1 053:42 Lafar4e Metro Land 303 657 4037 P.03 <br />~~ 818 GnWtnlel Bldg., 1~men eL Dawer, ColMedo 80QD3 <br />s <br />~ <br /> (:~. I t ~ L iJ ~ "~ ~ . <br /> . <br />FOR INSTRUCTIONS, SEE REVERSE SIDE <br />STATEMENT OF BENEFICIAL USE APR 2 7 1999 <br />WELL PERMIT NUMBER `4G 734 -~ ~~~ '~ •E ~ %•~~~' <br />~ <br /> <br />1. <br />WELL OWNER :r'.: <br /> NAME(S) ti+1061~~ PREAArX PnuCPG:fF. tlJf, <br /> <br /> Mailing Address Ir,4n W 12+h k/L <br /> City, St Zrp (~ n/t.r P,D 4n;tn4 <br /> Phone (?,~~ 1 1a5~- A-~.3I <br />2 WELL LOCATION: COUNTY_ Q~lamt OWNER'S WELL DESIGNATION Nnw~Aj ~- <br /> A2A5 i-. I121-h llvv ~LY~[YSnn ~ ~6~GLn40 <br /> (Address) ~ (GHl l~l (DPI <br /> 1/a or the 1/4, Sec.~_ Twp.~_ ^ N. or ^X S., Range (0'7 ^ <br />«®W. ~_P.M. <br />E <br /> 11 <br />rI--- <br />Distances from Section Lines Ft. from ~ N. or ~ S. Line, FL from L_l E or ^ W. Line. <br />3. The well is being used for the following purpose(s): EJa t~nrdtt vr, I eSScS "l'Q7'~' ~G S u r <br /> 5 ~ ~I <br /> <br />4. Water from the well was first used beneficially <br />q g <br /> . <br />undo[ this permit number, for the above described purposes on Q„r,1 2~ 19 <br /> (Do rtot roporl a date whkh n before gta iawad dale of tltla pertniq <br />5. The pumping rate claimed is N R galbns per minute. <br />6. The average annual amourrt of water diverted is CFO acre feel <br />7. The land area irtigated (watered) by water from this well is: ~ ^ Acres ar ~ Square feet, <br /> (Number) <br /> described as: NR <br /> -(Lega~lTeacnp on <br /> or as N A Subdivision Lot(s) Block FilingNnit <br />8. Well drilled by: ~-~raytl, Pi ~- t3rl • ~i~0~.: ~~ ~'1 mr~c ~m~Lf'r~+ 1nr l]c. No: ~_. <br /> Pump installed by: NA Lic. No: <br /> <br />9. Meter Mfg. by NA Serial No.: Dale installed: <br /> I {we) have read the statements made herein, know the contents thereof, and state that they are true to my (our) <br /> knowledge. [Pursuant to Section 24~-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury <br /> in the second degree and is punishable as a Class 1 misdemeanor.} <br />10 f~ame/ritte (PLleesa typo or prlrtq <br />vIJIi?, ~'Ol'.l ~Zmi;Z II~~( I f8 ~ gyp/ ~ ~ <br />1 at@, <br />l <br /> <br />,llv.r-nmt 4 i. '~F(,lXn/~ <br />' FOR OF E USE ONLY <br />Accepted that tizcse cc^3itioas of approval lib <br />stated on the permi L are ccmplied with„ <br />.~ , <br />~ '~~, <br />. MAY ~ 0 1S9 <br />State Engineer - eY Date <br />Court Case No. Div. Co. WD s MD Use <br />TDTAL P.03 <br />