PERMFILE55608

• Permit No: C1981012
• IBM Index Class Name: Permit File
• Doc Date: 12/11/2001
• Section_Exhibit Name: EXHIBIT 11 WATER WELL INFO PART 1
• Media Type: D
• Archive: No

WRJ. S•Re~. 76
Application must
be complete where
applicable. Type or
print in BLACK
INK. No overstrikes
or erasures unless
initialed.
COLORADO DIVISION OF WATER RESOURCES
818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203
PERMIT APPLICATION FORM
I A PERMIT TO USE GROUND WATER
1 1 A PERMIT TO CONSTRUCT A WELL
FOR: ( 1 A PERMIT TO INSTALL A PUMP
1 REPLACEMENT,FOR N0.
(X)OTHER Cpl ~V''r
WATER COURT CASE N
-mailing address
NAME RRS~ ~ Q2SDC'~C~f Inc
STREET Iy30rU 1flS~wr^Y 12
CITY w2S~C^ Jam- Go - BIC~i I
(State( (Z~p)
TELEPHONE NO.~~iS~ Bbd-,I161
(2) LOCATION OF PROPOSED WELL
County+~`~$ ~nt"~riS
_ - S w % of the NF '/., Section
IN.51 IE.WI ,
• (3) WATER USE AND WELL DATA
Proposed maximum pumping rate Igpml N
Average annual amount of ground wate~
to be appropriated lacre-feet):
Number of acres to be irrigated: ~/~
Proposed total depth (feed: ~ y
Aquifer ground water is to be obtained from:
frllvyl~ l
Owner's well designation S ~ -
GROUND WATER TO BE USED FOR:
( 1 HOUSEHOLD USE ONLY
1 1 DOMESTIC 111
1 1 LIVESTOCK (21
1 COMMERCIAL 141
no irrigation (0)
( )INDUSTRIAL 151
( 1 IRRIGATION (61
( )MUNICIPAL (81
1?(IOTHER191 MC~~fo~~^~
DETAIL THE USE ON BACK IN 11 f 1
(4) DRILLER
.Name L7 ~CD~n ()QJD~i
Street ~b00 W F)~/hD~2 Sf~Z~
City ~Otprq~0 SM%n9S C0~ $O~c7
(Sta a) (Zip)
Telephone No(~15) 6's l - js57 Lic. No. N~
FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN
Receipt No.
Basin

Dist.
CONDITIONS OF APPROVAL
This well shall be used in such a way as to cause
no material injury to existing water rights. The
issuance of the permit does not assure the applicant
that no injury will occur to another vested water
right or preclude another owner of a vested water
right from seeking relief in a civil court action.
APPLICATION APPROVED
PERMIT NUMBER
DATE ISSUED
EXPlRAT10N DATE
(STATE ENGINEERI
BY
t n