2008-03-13_PERMIT FILE - C1992081 ‎(2)‎

• Permit No: C1992081
• IBM Index Class Name: Permit File
• Doc Date: 3/13/2008
• Doc Name: Shallow Well No. 1 Well Information
• Section_Exhibit Name: Tab 07 Attachment 7-5
• Media Type: D
• Archive: No

Form STATE OF COLORADO
No. OFFICE OF THE STATE ENGINEER
GWS-11 g18 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
2006 phone -Info: [phone] Main: [phone]
Fax: [phone] htt ://www.water.state.co.us
CHANGE IN OWNERSHIP/ADDRESS
CORRECTION OF THE WELL LOCATION
Review instructions on the reverse side prior to completing the form.
NAME(S): Hayden Gulch Terminal, Inc.
Mailing Address: 701 Market Street, Suite 700
City, St. Zip: St. Louis, MO 63101-1826
Phone [phone]
This form is filed by the named individual/entity c
This filing is made pursuant to C.R.S. 37-90-143.
ng that they are the owner of
WELL LOCATION: Well Permit Number: 24576-F
For Office Use Only
well permitted as referenced above.
Receipt Number: 111449
County Routt Owner's Well Designation (optional) HG Shallow Well
(Address)
(City )
(State) (Zip)
SW1/4 of the NE 1/4, Sec. 10, Twp. 6 ®N. or ^ S., Range 88 ^ E. or ®W., 6th P.M.
1600 Ft. From ®N. or ^ S., 3200 Ft. From ^ E. or ®W.'Line.
Subdivision Name
Lot ,Block ,Filing/Unit
The above listed owner(s) say(s) that he, she (they) own the well described herein. The existing record is being amended for
the following reasons:
^ Change in name of owner ®Change in mailing address ^ Correction of location for exempt wells permitted prior to May
8, 1972 and non-exempt wells permitted before May 17, 1965.
Please see the reverse side for further information regarding correction of the well location.
I (we) claim and say that I (we) (are) the owner(s) of the well described above, know the contents of the statements made
herein, and state that the are true tom our knowled e.
Signatu e(s) of the new o er Please print the Signef=s~Nam~& Title Date
It is the responsibility of the new caner of this well to complete a d sign the form. Signatures of agents are acceptable if an
on final letter of a enc si ned b the owner is attached to the form u on its recei t.
For Office Use Only
State Engineer
By
Date
MR-16 7-5.1 Revised 11/07