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wRJ•75-70 <br />Index No. Z Z/ <br />~~+wD ,/' II <br />mp4eHa.1,161 <br />yield <br />eked By <br />STATE OF COLORADO ) SS y~ (,~ ~ y~1~~~ <br />CLAIMANT Is)S!____s•.~ /`~ E~~~'~'-'+'t-~7 <br />being duly sworn upon oath deposes and says that he (they)is (are) <br />the owner (s) of the well described hereon; the total number of acres <br />of land irrigated from this well is ~~~- , <br />work was commenced on this well by actual constr''u~~c//lion on the <br />day of19~: the sustained <br />yield from said well is~.~gpm, for which claim is hereby made <br />for / purpose (sl; <br />~ature <br />Address: <br />Su/bs~cribed and sworn to before me on this~day <br />of sf/~_t e ~~-i ~~.s~ 19 ~J/ <br />r-3r eo.-~;~_~~~-~;-piles eCtoEer ,q ,n~. <br />My Commission expires:. (~~ /~~J ~ .. <br />. (Beall ~~?.~i ~ ,F~~f/ <br />- ' Notary Pub <br />STATE OF COLORADO <br />DIVISION OF WATER RESOURCES <br />OFFICE OF THE STATE ENGINEER <br />MAP AND STATEMENT/F~ORpWATER W/ELL FILING <br />PERMIT NUMBER 1 t'S ~ ~h <br />WELL DATA <br />Date Completed q~-~/. ~o~~- ~/ ~/ <br />Sta[ic Water Level o" ~ -~^ <br />Total Depth of Well SSA` <br />• <br />a. <br />ro <br />DEC1911 <br />RECEIVED N <br />~ WATER 0.ESO~R~S ~~ <br />' tATE~tO NEFA~~,L <br />~///,/.~/ / WELL L ~J N (/,~ <br />y/r"V I~l~~ O£bG 6G LZyV 3T'~. <br />r County <br />~'/. of~'i , sec.//.~_ <br />T.~R.~___O_~P.M. <br />INDICATE WELL LOCATION ON DIAGRAM <br />NORTH <br />I I I <br />I I I <br />x 1 <br />I 1 <br />---r -- +- - - T --- <br />I I I <br />~ I I I <br />I ~ ~ <br />w ---~ --- <br />3 I I ---I -- ~ m <br />I I I <br />--~- --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 />GOVERNMENT SURVEY CORNERS OR MONUMENTS, <br />OR SECTION LINES BY DISTANCE AND BEARfNG. <br />ft. from section line. <br />(North or South) <br />ft. from section line. <br />(East or West) <br />Ground Water Basin <br />Water Management <br />District <br />Domestic wells may be located by the following: <br />LOT ~ ,BLOCK ///~~~~~/ ~~~ <br />SUBDIVISION ~'r~~~-zi~D <br />FILING p Os <br />ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF COLORADO ON THIS DAY <br />OF <br />19 _. <br />ATE ENGINEER <br />FORM 70 BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GoeeN Conies m~•^- ^^ filed with -~^ $tato cnninae. within 30 davc afro. rho r+'1 is enmrluted n. wirhln 7 ~/a..c <br />the average annual amount to be diverted is <br />acre•feet; this map and statement is filed incompliance with law; <br />he (they) has (have) read the statements made hereon; knows the <br />r~ntent thereof; and that the same are true of his (their) own <br />wledge. _ ~ <br />