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WRJ-25-70 <br />Index No. <br />IDWD <br />Completion <br />Yield <br />Checked By <br />STATE OF COLORADO ) SS <br />CLAIMANT (s) Talnnr# Warkhan <br />being duly sworn upon oath deposes and says that he Ithey)is (are) <br />the owner I s) of the well described hereon: the total number of acres <br />of land i«igated from this well is <br />work was commenced on this well by actual construction on the <br />-day of 19~: the sustained <br />yield from said well is `,~ gpm, for which claim is hereby made <br />purpose (s); <br />the average annual amount to be diverted is <br />acre-feet; this map and statement is filed incompliance with law; <br />he Ithey) has Ihavel read the statements made hereon; knows the <br />content thereof; and that the same are true of his (their) own <br />knowledge. <br />Signature is) X n f~-~~~~~~"- <br />Address: <br />~w~- IY,v~n~ ^n1 ^rsrr+n <br />Subscribed and sworn to before me on this <br />of <br />• STATE OF COLORADO • <br />DIVISION OF WATER RESOURCES <br />OFFICE OF THE STATE ENGINEER <br />MAP AND STATEMENT FOR WATER WELL FILING <br />PERMIT NUMBER~f~$Sr <br />19 <br />Water Management <br />'afashin¢},nn County <br />~ ;: of SB Y., sec <br />T. iN R. STl 6th P. M. <br />INDICATE WELL LOCATION ON DIAGRAM <br />ror SkooK .. ,. <br />Grgvel ',.. <br />Pi ~. ~WI°ll permlYs ~~ <br />WELL LOCATION <br />NORTH <br />I I I <br />I I I <br />I <br />---I- --+'---r--- <br />I I I <br />I I I m <br />I ~ <br />w ---I -- I D <br />3 ~ -T---r-- N <br />I i ~ m <br />L--J---L---L---~ I <br />i <br />SOUTH <br />WELL SHALL BE LOCATED WITH REFERENCE TO <br />GOVERNMENT SURVEY CORNERS OR MONUMENTS. <br />OR SECTION LINES BY DISTANCE AND BEARING. <br />My Commission expires: <br />(Beall <br />.-.<` <br />WELL DATA <br />Notary Public <br />ft. from secnon line. <br />(North or South) <br />from section line. <br />(East or Westl <br />Ground Water Basin <br />Dale Completed -~.Y 20, 1972 <br />Static Water Level R)t <br />Total Depth of Well fly?' <br />Domestic wells may be located by the following: <br />LOT <br />BLOCK <br />SUBDIVISION <br />FILING p <br />ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF COLORADO ON THIS DAY <br />OF 19_. <br />STATE ENGINEER <br />RM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />ITE AND GREEN copies must he filed with tha sta[a Engineer within 30 days after [ha well is completed or within 7 days <br />er expiration date of the permit. whichever is sooner: PINK COPY is for the Owner and YELLOW COPY is for [he Driller. <br />