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THIS FORM MUST BE <br /> SU6MITTED PRIOR TO <br /> THE EXPIRATION OF THE <br /> PERMIT. TYPE OR <br /> PRINT IN BLACK INK. <br /> <br />' COPY OF ACCEPTED <br />STATEMENT MAILED <br /> ON REQUEST. <br />' FOR DFFICE USE ONLY <br />D... Clr. <br />,STATE OF COLORADO <br />COUNTY OF T1r't'+ <br />PERMIT NUMBER 12537 <br />55. <br />'THE AFFIANT(S) rsoT+~a ~d Rock Comoanv, LZC. <br />whose moiling <br />'address is 10~~11 `inrtt't Rr~cT',tnn Rndd <br />City rro~r~~r~nn C'nlnr.ar~n ~(1F'r~_ <br />1]r.rU Iivl <br />LOCATION OF WELL <br />EXHIBIT G <br />(Cont'd) <br />co~nrr Adams <br />SE ;: of Iti. .IE v, s.~ron 9 <br />T..P• ~ S Rng. 67 >:d ,~ 6th P.M. <br />~1 ~WI <br />'being duly sworn upon oath, deposes and says that he (they) is (ore) the owner(s) of the well described hereon; the well is <br />I located as described above, at distances of Eeet from the section line and feet Srom the <br />I.O.TM OII ]OVLX) <br />section line; water from this well was first applied fo o beneficial use for the purpose(s) described herein on the <br />rL.]T o. r.mrl <br />day of -, 19_; the maximum sustained pumoing rate of the well is gallons per minute, the pumping <br />role claimed hereby is gallons per minute; the total depth of the well is feet; the average annual amount <br />of water to be diverted is acre-feet; for which claim is hereby mode for ___ <br /> <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 was completed in compii..nce <br />with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; ITe (they) has <br />(have) recd the statements/made hereon; knows the content thereof; and that the same are true of his (their) knowledge. <br />•".pavi3 L. Erickson, Assistant Secretary <br />Sub scribed.an ~~worn I //~~ FOR OFFICE USE ONLY <br />i to beforelne'on this.'~sr day of ~!_L( nAL Il'77~ ,. 19?~.__ ... - . _._ _. <br />;.•• }',, - ,' Il Court Core No. <br />.^ <br />' MyCommi~sion expire s'~,~.t?.-(t'7~Y/(t ~.~ N / ~/ /.i ~~ -.. ~ , <br />r Sac. /., <br />ltl ~, •) y <br />,..,•.. <br />ACCEPT57..FOR•. FILING BY THE STATE ENGINEER OF COLORADO - - <br />PURSUANT~TO' YHE FOLLOWING CONDITIONS: D~]I. B.]In Mon. D~]. <br />'DATE <br />COLO~O DIVISIOPV OF WATER R~URCES <br />300 Columbine Bldg., 1445 Sherman St. <br />Denver, Colorado 80203 <br />STATEMENT OF BENEFICIAL USE OF GROUND WATER <br />_~ AMENDMENT OF EXISTING RECORD <br />Prior. Mo. __ Dar Yr. <br />37 <br />STATE ENGINEER <br />BY <br />