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Required NE1/4 SWl/4 Section Township Range Principal Description: of the 26 3S 72W Meridian 6`h Gilpin County Distance from section lines (section lines are typically not droperty lined: 2250 Feet from South section line and 2000 Feet from West section line (see attached Exhibit A) Street Address: 1601 Highway 119, Black Hawk, CO 80422 Subdivision: n/a Lot: n/a Block: n/a 4. A. Source: Fractured aquifers tributary to North Clear Creek B. Depth: 950 feet 5, A. Date of appropriation: March 29, 2002 B. How appropriation was initiated: By inclusion of the well in the City of Black Hawk's Application for Plan for Augmentation in Case No. 94CW036. Applicant's well was included in the augmentation plan pursuant to the Fourth Amendment to Application in Case No. 94CW036 filed on March 29, 2002 and published in the March 2002 Water Court resume for Division 1. C. Date water first applied to beneficial use: April 5, 2005. 5. Amount claimed: 15 gpm, absolute. 6. If well is non-tributary: n/a 7. Proposed use: A. If irrigation, complete the following: n/a B. If non-irrigation, describe purpose fully: The water will be used for municipal purposes, including drinking water, toilets, showers, washing machines, ice makers, dishwashers, and emergency eye wash stations, and other municipal uses at the Applicant's wastewater treatment plant. 8. Name(s) and address(es) of owner(s) or reputed owners of the land upon which any new diversion or storage structure, or modification to any existing diversion or storage structure is or will be constructed or upon which water is or will be stored, including any modification to the existing pool: Applicant. 9. Remarks: This well will divert under its own priority when water is available under the water right to be decreed herein. At all other times, water pumped by this well is augmented pursuant to the decree entered in Case No. 94CW036 on August 22, 2003. JDF 298W R10/04 APPLICATION FOR UNDERGROUND WATER RIGHT Page 2 of 3