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THIS FORM MUST BE <br />SUBMIT T'ED PRIOR TO <br />TH2 E%PIRA7ION OF THE <br />~E RMIT. TYPE OR <br />PRINT IN BLACK INK. <br />COPY OF ACC EP IED <br />-'TEME HT MAILED <br />EOUEST. <br />OFFICE USE O <br />D... ~ CIY. <br />STATE OF COLORADO <br />COUNTY OF <br />'702: 5 <br />LOCATION OF WELL <br />THE AFFIANT(S) d O'/j/f~~yJ /r t^ H.p(/F7 c,,,nrr ~ ~$ L7 A//MSS <br />whose mailing <br />address IS ~ ~r ~j ~ •J~ ~ o{ tho r) [~~ I/, S+ction ~_L <br />City ~[/ES' Ir7 /1~ (•O~~ S~d~! Trp. sL.~ S .Rnq. _$_!L .~NP.M. <br />Uro[I 1x1+1 IH o[ 31 E o+ wl <br />being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well describ'e' rb~e~~yon; the,,well is <br />located os described above, at distances of JAS Feet from the .SP({Ti% section line and ~ feet from the <br />1+o+.x a+ aou*+1 <br />GAL section line; water from this well was first applied to a beneficial use for the purpose(s) described herein on the <br />I[.,, ,+ w[~n <br />day of M~ ~ _ , 19~ the maximum sustained pumping rate of the well is gallons per minute, the pumping <br />claimed he/reby is ~.,~ gallons per minute; the total depth of the well is ~ 1. feet; the average annual amount <br />ter to be diverted is ~_ acre-feet; for which claim is hereby made for O/N f S T / C'_ oL' <br />Li vE $ Tae~,~ purpose(s); the legal description of the land on which the water from this well is used is <br />G.? fl G f'{F_ t t LU%,s t Tied ¢ / T 7~,~~/~' LU ~.OM which totals <br />acres and which is illustrated on the map on the reverse side of this form; that this well was completed in compliance <br />with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he (they) has <br />(have) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge. <br />Signature(s) ~ y LQ.it!-~ '~/ ~ <br />Subscribed and swam!~ ~ FOR OFFICE USE ONLY <br />to before me on this ~ai_, day of ~_ , 19 <br />My Commission expires: _ M1-GDRIRIISSFOn E'mires Feb.22,1OT/ <br />If[.U <br />orA+. ru[L1c .. <br />ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO <br />PURSUANT TO THE FOLLOWING CONDITIONS: <br />Court Ca[+ Na. <br />$e c. <br />'6 '/. Y,, <br />wan u[[~ <br />Di[t. ~ / Baain ~ Man. Dis <br />Prior. Me. _ Dey _ Yr. <br />• <br />. • <br />JUL 2 5 ~ <br />7ATE STATE ENGINE <br />T <br />[ JUN1973 <br />COLORADO DIVISION OF WATER RESOURCES ~ RECEIV <br />300 Columbine Bldg., 1845 Sherman St. ~ WAtE0. 0.E50 AC <br />~ STATE EN EEI <br />i Denver, Colorado 80203 sus, COL <br />'n[[CL6ti` <br />^~ STATEMENT OF BENEFICIAL USE OF GROUND WsI~R <br />AMENDMENT OF EXISTING RECORD La%Jc KEG~ST,ZAi /~ <br />PERMIT) NUMBER <br />} SS. <br />