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wR!-2S7o <br />field <br />STATE OF COLORADO 1 SS <br />STATE OF COLORADO <br />DIVISION OF WATER RESOURCES <br />OFFICE OF THE STATE ENGINEER &I'~ <br />MAP AND STATEMENT FOR WATER WELL FILING <br />PERMIT NUMBER tfS~} 6`r <br />CLAIMANT (sl ~~/ ~y/t+~RQ <br />being duly sworn upon oath deposes and says that he (they) is (are) <br />the owner (sl of the well described hereon; the total number of acres <br />of land irrigated from this well is ~ „~t~ r '~ , <br />work was commenced on this well by actual construction on the <br />r ~j~ <br />day ofQ-~~~ 19J_L: the sustained <br />yield from said well is~gpm, for which claim is hereby made <br />for ~ r purpose (s): <br />the average annual amount to be diverted is <br />acre-feet; this map and statement is filed in compliance with law; <br />he (they) has (have) read the statements made hereon; knows the <br />content thereof; and that the same are true of his (their) own <br />~~° T ~~v <br />pE~19~1 <br />~GE1~v~~ <br />~~~~04 <br />WELL LOCATIO~Y 9Sb£ZL~ {, <br />r k <br />~QO /~~ Caunq <br />T. 3.3 `~ R.~G "_. u ~ P.M. <br />INDICATE WELL LOCATION ON DIAGRAM <br />NORTH <br />I~ I I <br />I I I <br />I I I <br />---r -- +--- T --- <br />I I I <br />I I <br />I ~ m <br />~ ---; ---r---~-- y ~ <br />3 I I I m <br />I I I <br />--J- --L---L--- <br />I I I <br />I I I <br />I I I <br />SOUTH <br />WELL SHALL BE LOCATED WITH REFERENCE TO <br />GOVERNMEM SURVEY CORNERS OR MONUMENTS. <br />OR SECTION LINES BY DISTANCE AND BEARING. <br />My Cpmmission expires:. ~ ~~ ~ y- <br />Notary Publi <br />WELL DATA ^ - , <br />Date Completed ~/ q~'~+ ~ ~ . /~ ~~ <br />Static Water Level ~".~ <br />Total Depth of Well ~ O~1 <br />ft. from section line. <br />(North or South) <br />ft. from section line. <br />(East or West) <br />Ground Water Basil•I <br />Water Management <br />District <br />Domes//ti~~c wells may be located by the following: <br />LOT.S~.BLOCK <br />SUBDIVISIOgN <br />FILING H 2 ~ <br />ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF COLORADO ON THIS <br />• OF <br />19_. <br />ENGINEER <br />DAY <br />FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copies must be tiled with the State Engineer within 30 days after the well is completed or within 7 days <br />Subscribed and sworn to before meson this~day <br />