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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 /> hftp://water.state.co.us/default.htm <br />REGISTRATION OF EXISTING WELL <br />NAME, ADDRESS AND PHONE OF THE WELL OWNER: <br />NAME(S) <br />Fredrick G. Hoe tner et All Partners c/o Scott Hayden <br />MAILING ADDRESS <br />360 S. Monroe, 5th Floor <br />CITY: STATE: ZIP CODE: <br />Denver CO 80209 <br />TELEPHONE NUMBER E-MAIL (OPTIONAL) <br />(303) 756-2999 <br />WELL LOCATION County Routt Owner's Well Designation (optional) OK2 <br />N/A N/A CO N/A <br />(Address) (City) (State) (Zip) <br />SW 1/4 of the NW 1/4, Sec. 17 , Twp. 4 ® N. or ? S., Range85 ? E. or ® W., 6th Principal P.M. <br />Distance from Section Lines 1229 Ft. Z N. or ? S. Line, 151 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: Easting 333528.32 <br />Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true <br />north. M Zone 12 or ® Zone 13 <br />Was GPS unit checked for above items? ® YES ? NO Northing 4465258.54 <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 9/5/79 <br />The total depth of this well is 20 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 />Signat a of the Well Owner Print Name and Title of Well Owner Date <br /> - <br />?-° <br />1k o ? n 1 il¢r ? T. it'LtitJlr?,?r s <br />t <br /> <br />For Office Use Only <br />WE <br />WR <br />CWCB <br />TOPO <br />MYLAR Div WD Basin MD