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Form STATE OF COLORADO For ORtce Uec Only <br />~- OFFICE OF THE STATE ENGINEER ~ <br />GWS-t I 818 Certtemlat Bidp.. 7313 Sherman SG, Denver, CO 80203 <br />~~ Phone - Irt1o: (303)888-3587 Main: (309) 8883587 <br />Fete 303 8863586 :IANYW.walafAlOte.OD.Ua <br />CHANGE IN OWNERSHIP/ADDRESS <br />CORRECTION OF THE WELL LOCATION <br />Review tedruetlem ea the rrrvsrre elde prior m we+p7etiaa the isrn <br />r <br />i Name. address and dtane of 8ls oersan claYnirw awnershio of the well: <br />~iA. 2~ Iloooc+n~w <br />NAME(S): ~'n~ <br />l <br />Melling Addreea: ye w~ 'u~ <br />M <br />Ciy, &. zip: 36D So, 'IAanree S ~ ~nyw r,o`~) <br />Phone 3D3 ~ t: - <br />This farm to /dad by the named indiNduetlen8ty dalminp drat they are the owner of the well permiMd es referenced abaw. <br />This fi is made ursuam m C.R.S. 37-80-143. <br />WELL LOCATION: Wall Permit Number. 88157 Ret~ipt Number: <br />County Raut! OwneYa Well Designation (op8onal) ~ <br />(Address) (City) (State) (Zip) <br />jet M of uro~ 1l4, Sec, ,~, Twp. 4 ®N. or ^ 3., Barge &~ ^ E. or ®W .. 8th P.M. <br />Distance tram section Lines: 1100 Ft. Fmm ®N. or ^ S.. 360 FL From ®E. rtr (] W. 1me. <br />Subdiviabn Name lot, , 91ack, , FdlnpNnk`_ <br />Tate above listed owner(s) say(s) that he, she (then) own the »+ell dcacrbedlterein. The exiatlnp record W being amended ror <br />the }olk7wing roeaona: <br />Change in name of owner ®Chenpe in madinp sddresa Q Correction of (oeafion for exempt wells permitted prior to May <br />8,1972 and non-exempt wets 17ar77tllled before May 1 T, 1985. <br />Please eee the reverse bide for hlrthar inlomlation reperdi7g correction of the well locetbn. 1 <br />1 (vve) daim and say that 1(we) (ere) the owner(s) d the wall described shwa, know ttte carllelds of the atalerrtenM made <br />herein end ebb that the are true tom our knotty <br />Siprtature(s) of the new owner P <br />ese <br />print t <br />h <br />e Sip <br />ner'9 Name A Title <br />b D <br />~de <br /> ' <br />/ <br />( <br />( <br />' <br />~ <br />)CO {' Y7[lVOlh r OLJneY p <br />/~~/~H <br /> <br />IL H ate recponslblldy of ate new owner of mie wed to complete entl eipn the form. Signatures of agents aro etxxptaMe d en <br />9~te Ergirleer By Dots <br />