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THIS FORM MUST BE <br />SUBMITTED PRIOR TO CO LO~DO DIVISION OF WATER R OURCES <br />'THE EXPIRATION OF THE EXH/I~BIT G <br />PERMIT. TYPE OR 300 Columbine Bldg., 1345 Sherman St. ~ (COI7t' d) <br />PRINT IN BLACK INK. <br />COPY OF ACCEPTED Denver, Colorodo fS02f13 <br />'ST aT EME N7 MAILED <br />ON REOU EST. <br />STATEMENT OF BENEFICIAL USE OF GROUND WATER <br />FOR OFFICE USE ONLY _~_ AMENDMENT OF EXISTING RECORD <br />D~.. C+r. <br />PERMIT NUMBER ~?5"~%, <br />,STATE OF COLORADO <br />} SS. <br />COUNTY OF ~~A:15 <br />' LOCATION OF WELL <br />THE AFFIANT(S) ~nsol ; a °GT_$OStc ~'o^tnany Inc cevnlr Adams <br />whose mailing <br />'address is 1 0991 'forth 3r~ qh+on Road S£ y of Il,e TIW ;:, se[licn 9 <br />'Gty - 'tondo raon Col n~ado 24040 -' T-v ? ~- , Rng. ~Z_ ~L , F, t-h P.M <br />r,r.r[r r: r.l Ti°7{sl }~e~wl <br />being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon; the well is <br />'located as described above, at distances of ~ feet from She ~ section line and feet from the <br />(ao•rn o. aournl <br />section line; water from this well was first applied to a beneficial use for the purpose(s) described herein on the <br />1!.ar o• ..[arl <br />doy of 79 the maximum sustained pumping rate of the well is gallons per minute, the pumping <br />rate claimed hereby is <br />of water to be diverted is <br />gallons per minute; the total depth of the well is <br />feet; the average annual amount <br /> <br />acre-feet; for which claim is hereby made for <br />purpose(s); the legal description of the land on which the water from this well is used is <br />which totals <br />acres and which is illustrated on the map on the reverse side of this form; That this well wos completed in compliance <br />with the permit opproved therefor; this statement of beneficial use of ground water is filed in compliance with law; he (they) has <br />' (have) read the statements made hereon; knows the content thereof; and That the same are true of his (their) knowledge. <br />$ignatur e(s)+ ~~~~ <br />.• , 4 ~ I • Dave L. Ericxson, ss>_s a_*T~ ecre ary <br />$ubscribed~and sworn rl ~ FOR OFFICE USE ONLY <br />to b~'o rerm 1 on.this.~->'e••~/ doy of _/ /// i ~ 19 ~ ._. __ - <br />~f ~ ~ i ~ ~ ~ ~ ~. ~~ I -7 py~l Coo•r Caae No. <br />tdy•Commission expires: __~•'V~~9 -~~~~~~J( ~~/ `1 /.~C ~- ~ - <br />i)r '. :~dl.~t Y '~~ i Sec. iii, i' rii. <br />~ ~ ~ <br />.• •••• wo+.a u•uc C' well Uae <br />' ACCEPTED. F.OR FILING BY THE STATE ENGINEER OF COLORADO <br />PURSUANT TO THE FOLLOWING CONDITIONS: D.e+. Be+~n Man. Dis. <br /> <br /> <br />DATE <br />Prior. Me. __ Doy _ Yr. I <br />36 <br />STATE ENGINc ER <br />