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.RJ-:5.75 <br />"TPE OR <br />PRINT IN BUCK INK. <br />JPr OF •CC EP TED <br />' 'EuE NT MAILED <br />~OUEST <br />COLORADO DIVISION OF WATER RESOURCES <br />300 Columbine Bldg., 1d45 Sherman St. <br />Denier, Colorado 80203 <br />STATE OF COLORADO <br />COUNTY OF <br />S$ <br />AFFIDAVIT <br />L/ <br />RECEIV~~ <br />STATEMENT OF BENEFICIAL USE OF GROUND WATER <br />AMENDMENT OF EXISTING RECORD <br />LATE REGISTRATION <br />PERMIT NUMBER P~5 7'l LOCATION OF WELL <br />SEP 20' <br />WATER i7 F~iFiR: <br />STATE ENgNC` <br />tXKtL <br />THE AFFIANT(S) ~~)Rf2F I I G.,. Atd C.a7rF,^ir_ e k'. Pr~l-y ceur., ~H.S ~ti'./)I 1+S i <br />+ho se mailing _ I-CT ~~ $TO Ner.:'gll PIN~.AF <br />address is RI'0L~ /3~X .~ 3 / ~ I~ E / ~ of it,. -+1LJ %L %:, se[.~o^ 3CT <br />irf,f ;~/,v-1 C'. ; I ;, r a ~ 53l o ~ ~ c ~W ~ ~'t P M <br />City b rI ~ T_o. ~ _.2- R^g. ~ ~_ <br />i+r ..[1 41•I iv o• 5~ ~E n• wi <br />being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon, the well is <br />located as described above, at distances of feet from the section line and feet from the <br />iu G.._ ,. +0~._1 <br />section line; water from this we)I was first applied to a beneficial use For the purpose(s) described herein on the <br />day of 19_; the maximum sustained pumping rate of the well is gallons per minute, the pumping <br />•~• claimed hereby is _ gallons per minute; the total depth of the well is feet; the average annual amount <br />:water to be diverted is acre•feet; for which claim is hereby made far <br />purpose(s); the legal description of the land on which the water from this well is used .s <br />which <br />acres are irrigated and which is illustrated on the map on the reverse side of this form; that this well was completed in <br />compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he <br />(they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge. <br />(COMPL~ETE`REVERSE SI OF THIS FORM) J ` <br />Subscribed and sworn /_ ~~/ <br />to before me on this pday of ~ia..l~ 19 Lj>. <br />My Commission expir s: 7S ~ -3 ~ ~ / 7 <br />+r .. ~ / <br />• •VEIIC <br />ACCEPTED FOR LING BY THE STATE ENGINEER OF COLORADO <br />PURSUANT TO THE FOLLOWING CONDITIONS: <br /> <br />FOR OFFICE USE ONLY <br />Covn Cau No. , <br />P,:o. r.~a. Dar __ Y. <br />D... ~~,r. 3G <br />s.[ 'r.. 'e. '.. <br />wen u+. / <br />D.+ ~_ Bo+~^ Man D~+ <br />• , <br />iAN 04 1977 !~~ ~~~ ~, , , ,a,-, . ~~~ <br />__-E DL'tVJ•~I STaTE F~DINEER Bv~ <br />