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<br /> <br />' ,,.,~ <br />THIS FO R.'+ MUST BE <br /> SU9MITTED PRIOR TO <br /> THE E%PIRATION OF THE <br /> PERMIT. TYPE OR <br /> PRINT IN BLACK INK. <br /> COPY OF ACCEPTED <br /> STATEMENT MAILED <br /> ON RE OU EST. <br />FOR OFFICE USE ONLY <br />Dlv. _ C+r~ <br />i STATE OF COLORADO <br />COUNTY OF <br />LOCATION OF WELL <br />THE AFFIANT(S) C^'1^0.7 ~ c.~ted-T3c1c•C ^Or.r-~~.lvr rr~r•_ Cou~ry Arlamg <br />'whose moiling ~ ~ - . <br />address is ll1q r11 `7nY-i-h Rricr?ttnn Rnad SF '/. of rF. NF. '/., Soc6oe _s_ <br />(City Rp.y~prCnnr. (rplnrar3n R/1F4(t ---- 7-P.~~.Rr,y.~~_~tL_.fj-ttl-PM. <br />Isr.rel I:+.1 ~+.~sl ~.rl <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 the section line and feet from the <br />1+o~r. ow eo urw) <br />section line; water from this well was first applied to a Beneficial use for the purpose(s) described herein on the __ <br />day of 19_; the maximum sustained pumping rate of the well is gallons per minute, the pumping <br />rate claimed hereby is gallons per minute; The total depth of the well is ~ feet; the average annual amount <br />~ of water to 6e diverted is <br />1 <br />COLORADO DIVISION OF WATER RESOURCES <br />300 Columbine Bldg., 1345 Sherman St. <br />Denver, Coloro do 80203 <br />STATEMENT OF BENEFICIAL USE OF GROUND WATER <br />~ AMENDMENT OF EXISTING RECORD <br />acre-feet; for which claim is hereby mode {or <br />PERMIT) NUMBER ~t~~~T <br />} SS. <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 compliance <br />with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he (they) has <br />(hove) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge. <br />Signature(s) .. '•y2y~f~ (_`_"lr~-f__ <br />,° l:av~t2, L:, Erick§on, Pssistant Secretary <br />I Subscribed and;}yvorn "~/ <br />to before me qn:}his, ~ •day of (/ rJ I1 /_14't~ f9'7i _ _. <br />t V r/ ~ _ <br />fAy Commission gxPires: ~y'~P. ~ ~. .~ / ~~~~ <br />' , , <br />urs1J ~t I f ,) 1.' ~ . <br />. , -, , ~ .o..,r~.~,~ <br />ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO <br />PURSUANT TO THE FOLLOWING CONDITIONS: <br />i - <br />._., - <br />FOR OFFICE USE ONLY <br />Coorr Case No. <br />Sec. <br />w~D u:. <br />EXHIBIT G <br />(Cont'd) <br />I <br />Dist. Basin ~~~-~ ~ Mon. Dia <br />Prior. Mo. _ Doy _ Yr. <br />' ss <br />DATE STATE ENGINEER <br />