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Form STATE OF COLORADO For Office Use Only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-1 g18 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />6/2006 (303) 866-3581 Fax (303) 866-3589 <br /> htt ://water.state.co.us/default.htm <br />REGISTRATION OF EXISTING WELL <br />NAME, ADDRESS AND PHONE OF THE WELL OWNER: <br />NAME(S) <br />Robert S. Dick and Kathryne E. Crawford <br />MAILING ADDRESS <br />P. O. Box 776236 <br />CITY: STATE: ZIP CODE: <br />Steamboat Springs CO 80477 <br />TELEPHONE NUMBER E-MAIL (OPTIONAL) <br />(970) 846-8786 <br /> <br />WELL LOCATION County Routt Owner's Well Designation (optional) OS-O1-0007 <br />N/A N/A CO N/A <br />(Address) (City) (State) (Zip) <br />SW 1/4 of the SW 1/4, Sec. 30 , Twp. 5 ®N. or ^ S., Range85 ^ E. or ®W., 6th Principal P.M. <br />Distance from Section Lines 409.7 Ft. ^ N. or ®S. Line, 562.9 Ft. ^ E. or ®W. Line. <br />PLEASE ATTACH A COPY OF A CURRENT DEED FOR THE SUBJECT PARCEL <br />Subdivision Name N/A ,Lot ,Block ,Filing/Unit <br />Optional: GPS well location information in UTM format. The following GPS settings are required: Fasting 332434.45 <br />Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true <br />north. ^ Zone 12 or ®Zone 13 <br />Was GPS unit checked for above items? ®YES ^ NO Northing 4469110.20 <br />The well has historically been used for the following purpose(s): Monitoring Well <br /> <br />Water from the well was first used beneficially by the original owner for the above described purposes on 10/29/1979 <br />The total depth of this well is 55.8 feet. <br />The pumping rate of this well is N/A gallons per minute. <br />The average annual amount of water diverted is N/A acre-feet. <br />The lawn and garden irrigated (watered) by water from this well is N/A ^ Acre or ^ Square feet. <br />Number <br />The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant to <br />C.R.S. 23-3-104(13)(a). I have read the statements herein, know the contents thereof, and state that they are true to my knowledge. <br />Signature(s) of the Well Owner Print Name and Title of Well Owner Date <br /> <br /> <br />For Office Use Only <br />WE <br />WR <br />CWCB <br />TOPO <br />MYLAR Div WD Basin MD <br />