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Form <br />No. <br />GWS-10 <br />6/2003 STATE OF COLORADO <br />OFFICE OF THE STATE ENGINEER <br />818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />(303)866-3581 Fax (303)866-3589 or Office Use Only <br />STATEMENT OF BENEFICIAL USE <br />Insert the Well Permit Number <br />Name. address and phone of the well owner: <br />NAME(S) <br />~ <br />Mailing Address <br />City, St. Zip <br />Phone ( ) <br />WELL LOCATION: County Owner's Well Designation <br />(Adtlress) (City) (State) (Zip) <br />1/4 of the 1/4, Sec. _, Twp. ^ N. or ^ S., Range ~ E. or ^ W., P.M. <br />Distance from Section Lines Ft. From ^ N. or ^ S., Ft. From ^ E. or ^ W, Line. <br />Subdivision Name Lot ,Block ,Filing/Unit <br />The well is being used for the following purpose(s): <br />Water from the well was first used beneficially under this permit number, for the above described purposes on <br />(Do not report a date o(use before the issued date of this permit.) <br />The pumping fate Claimed is gallons per minute. (From the Pump Installation and Test Report.) <br />The average annual amount of water diverted is acre feet. <br />The land irrigated (watered) by water from this well is ^ Acres ^ Square feet, described as: <br />NumUer <br />or as Subdivision Lot(s) Block Filing/Unit <br />Well constructed by: License No. <br />Pump installed by : License No. <br />Meter Mfg. By : Serial No. Date Installed <br />I (we) claim and say that I (we) are the owner(s) of the well described above, know the contents of the statements made herein, and state <br />that they are true to my (our) knowledge. <br />Please print the Signer's Name & Title Signature(s) of the owner. Date <br /> <br /> <br />For Otfice Use Only <br />State Engineer By Date <br />