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Form STATE OF COLORADO For Office Use Only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-1 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />6/2006 (303) 866-3581 Fax (303) 866-3589 <br /> http://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 Kathryn 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 />WELL LOCATION County Routt Owner's Well Designation (optional) 05-01-0007 <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 Lot , Block , Filing/Unit <br />Optional: GPS well location information in UTM format. The following GPS settings are required: Easting 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 />Northing 4469110.20 <br />Was GPS unit checked for above items? ® YES El NO <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-blass 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 />Sign tur )Of h w er P ' Name and Title of Well O ner <br />03 f, Rr Dat <br />IS 61 <br /> <br /> <br />For Office Use Only <br />WE <br />WR <br />CWCB <br />TOPO <br />MYLAR Div WD _ Basin MD