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rNls Foaw Must 9E <br />SUeMITTEf 'PRIOR TO <br />THE EXPIRATION OF THE <br />PERMIT. TYPE OR <br />PRINY IN BLACK INK. <br /> <br />101 Columbine Bldg., 1845 Sherman St. <br />Denver, Colorado 80203 <br />_~STATEMENT OF BENEFICIAL USE OF GROUND WATER <br />AMENDMENT OF EXISTING RECORD <br />PERMIT NUMBER 5~ ~"1-~y <br />STATE OF COLORADO l <br />COUNTY OF ~ f? cS ~// / /V{ ,4 d t SS. <br />RECEIVED <br />lil~l 2'72 <br />Netrs+ <br />~eNtgtu~rar~t <br />ram: <br />THE AFFIANT(S) ~ ~ /y ~ ,~ e ' /d p ~- Q 1'Y~ l // <br />whose address is oS7`o N e t4/A ~- ~ / ~, f) Z hL We s f a „/ ~ o ,~. O , ~ / ~ 9/ <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 />,,/' i <br />located in the~t/y of the t/4 of Section ~~ ,Township 3 3 ~ , <br />1. / (N. or a.) <br />Range ~O ~w , ~_P.M. at distances of feet from the_ section line <br />(E or W.) ~ (North or South) <br />and feet from the section line; the total depth of the well is ~5 -feet; water from this well <br />(East or west) <br />was first applied to a beneficial use for the purpose(s) described herein on the~Zday of ~ fl / , 19 ~~ ; <br />the maximum sustained pumping rate of the well is ef~ gallons per minute, the pumping rate claimed hereby is- /~ - <br />6_„ons per minute; the average annual amount of water to be diverted is_ ~ acre•feet;for which claim is hereby <br />for Qoil't e 5'>L / ~- purpose(s); the legal description of the land on which the water <br />from this well is to be used is N ~/`~ °~ ~W /¢ ~ ~d f io nl 3~ 7~e`'. 33 S R • (e B w - ~ ~ n1 . <br />which totals acres and which is illustrated on the map on the reverse side of this form; that this well was completed <br />in compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with <br />law; he (they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his <br />(their) knowledge. <br />v <br />Subscribed and sworn to before me on this / 7 '~ ~ day of <br />-----~ 19 ~oY. . <br />My Commission expires: ~~~ ~~1 r/ ~ _ <br />tsaaD <br />ary Public <br />ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF <br />COLORADO ON THIS DAY OF 19-. <br />ENGINEER <br />WHITE COPY FOR DIVISION OF WATER RESOURCES <br />PINK COPY FOR WELL OWNER <br />7taearnalnrt of appropriation In acre feet Is not considered to be mate. <br />rtalfn the terms of this permit pursuant to S~ct:on lk&21.55 CAS, <br />FOR OFFICE USE ONLY <br />Prior. Date-, 19_ <br />Well Use <br />-t/.. -ya. -t/. Sec.- <br />T. - -. R. - -, --._P.M <br />Yield --W.D. ~~.- <br />Co. <br />Index <br />