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Form . ' STATE OF COLORADO or Office Use Only <br />Nd: OFFICE OF THE STATE ENGINEER <br />GWS-10 g18 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />32003 (303)868-3581 Fax (303)866-3589 <br />STATEMENT OF BENEFICIAL USE <br />Insert the Well Permit Number 057737E <br />Name. address and phone of the well owner: <br />NAME(S) Four States Aggregates, LLC <br /> <br />Mailing Address PO Box 1568 <br />City, St. Zip Cortez, CO 81321-1568 <br /> <br />Phone (970 ) 565-3368 <br />WELL LOCATION: County Montezuma Owner's WeII Designation Line amp Pit <br />21944 State Hiqhway 145 Dolores CO 81323 <br />tnddreae> (cur) (~) laP> <br />SW 1/4 of the SE 1/4, Sec. 22 Twp. 38 X^ N. or ^ S., Range 14 ^ E. or X^ W., 10 P.M. <br />335 <br />1510 <br />x^ <br />^ <br />~ <br />^ <br />Distance from Sedion Lines <br />Ft From <br />E. or <br />N. or <br />S., <br />Ft From <br />W. Una. <br />N/A <br />Subdivision Name <br />Lot , Bock, Fllln nit <br />The well is being used for the following purpose(s): Exposure of Ground Water in A (Gravel) Pit <br />and use of water for washing, dust control, and incidental use <br /> <br />Water from the well was first used benefidalty under this permit number, for fhe above descibed purposes on 1 AUG 2 ~ 0 2 <br />(DO rat report a dale oT use before Cie Issued date of this permit.) . <br />The pumping rate claimed Is N A - gallons per minute. (Fran the Pump InstallaCori end lest Repat) <br />The average annual amount of water diverted Is aximum ~ acre feet <br />The land irigated (watered) by water from this well is N/A ^ Acres ^ Square feet, descr(t>ed as: <br />N/A Number <br />or as N/A SubdMslon Lot(s) Block FilingNnh <br />WeII consWCled by: our a es ggrega es ug pi license No. N/A <br />Pumpinstalledby: Four States Aggregates LLC (will placeloperate ucenseNo. NIA <br />Meter Mfg. By: N/A: ri0 d15Charge aS yet Serial No. Date Installed <br />1(we) claim and say that I (we) are the owner(s) of the well described above, Imow the contents of the statements made herein, and state. <br />that they are true to my (our) knowledge. <br />Please print the Signers Name 8 TiOe Signature(s) of the owner. Date <br />Aryol Brumley ~. 2 tU~/ <br />c~ <br /> <br />Manager, F S A LLC <br /> <br />For OCice Use Only <br />State Engineer By Date <br />