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<br />n ~ ,..,. <br />t..r a. ~;.010R.1C0 Cii/ISIO?~ GF ~Yb.iEA ttEStttJ"C65 <br />roar iw pl AC4J~ J+~ Co1v~Liw. Ef•1~., IJ~4 c!,r•~rn SI. <br />CJ-• 01 Aj ,_[. !~ Dlwr•r, CaIOrOL+ FU[')J <br />/+A /l~r wl rrulfa <br />ow+fovcly SLATE OF COLORADO <br />COU'tIT Y OF ._ _..._ ._ ~ SS <br />~::,~; <br />.. .. f.: ~ : rr • <br />,~ STATEMENT CF OIIIEFICIAL US9 CP GROUI'D rATER <br />~~ Afet~NOUEMT OP EAISTIi1G R.cCORO <br />....._ LAT! REGISTRATICT~ ' <br />~ ... ~ <br />P!Gl61T HIJh!9ERQ'x~~~.f=F L_CCATI^•t Cr.' r 4LL <br />THE AFFIANTISI_ John Ha ;'• ~oIL_ _!_ r...., _~,r.n.An•!.;--:L I ____.. <br />whe t0 mmLnq <br />addren n . Z: r'~ I6~! 7hG~ ._~ .` 41 ___ ~.r ... __ :'7. I w •.. --17'- <br />pry `~._~.-t,~~~~':~-a~t~_._ •-..39_ _:1._ °-+ --C3..I.~:- _~-`'~. <br />be q duly sworn upon oath, •Ieposea a.d soya i rol he !they) ra iota! rhs o.nwl sl of the wail descr,brd, hexes+, •hr .-•, ~. <br />I <br />located ea deacr gybed above, m d~s~ancea of feet Iron rhs ._._, season Lne acd ,._i I __- 7r•r !r a^. •~- <br />action line, wate.i from rhea we~l wos /teat applied to 0 6enelic.al we fee •he pvpo+ehi descr•F~ i F-re~, .~ the 31 <br />... ..r. . <br />doy of ~^~- 19 S{ , fhe mnumum tuctarne! pump~nq rare of the cell ,a ~+_i_ gallons Doi m.cuf r, $•e por^p•• s <br />rat. clo~med herby .a ._~? _ gallom per n.rnure, tM totol depth nl the »ell rs 27 Lrr, the a' `Wage a»nual a^v r• <br />of woes. to Se drvr red ,a _150 e;mleer Pot wh~cM cia~m .a he•eby mad. In. i^i!?~LSe1yd`^^_ lo! C~_;~c~~, <br />tj nh t,M W 1.1 _],~t,_ avrpacei s); tM logo! de scr ror,on a( rho lord on wh.<h the »arer Ld I rh•s •.e't . a used ~. <br />.., Y~ <br />w~~ :S <br />erlfe on Irtlgmed <md which Ic illuatratad on the mpp en the rotors dds of thi a ben; that thin veil was tsnpteted ~~ ' <br />compliance with the permit enp•eved therefor; thin atotament of btneficinl use el pound s.eter it tiled in n ~.pli^nae with law, Fa <br />Ithry- lira (hovel Wad tF:o ctatem r.tn mode hereon; krrowf the eenlnt threw/; and that tSa came ere true o~i i if '!'~oirl 4r.a»le?;t. <br />(CCdPL:TE REVERSE aDt OP TTIIS FORAtI <br />Signoturel sl <br />Subscribed xd sworn <br />ro bdore me on thin day of _ , 19 _ _. <br />My Com:nrtaian eepue c: <br />ACCEPTED FOR FILING 9Y Tr1E STATE. ENGINEER OF COLORADO <br />PU4:UarlT TO TttE fOLLr~wttlG COnD1T10;:5 <br />wa cent i f! o~ay <br />Pr. _ u, _ ~ C e. ~ •. <br />,~ ~ <br />7 .. ~ y <br />rev wr ~_. .1 II ,~.~ ^ _• <br />- i <br /> <br />