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Form STATE OF COLORADO For Office Use Only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-11 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />8/2007 Phone - Info: (303) 866-3587 Main: (303) 866-3581 <br /> Fax: 303 866-3589 http://www.water.state.co.us <br />CHANGE IN OWNERSHIP/ADDRESS <br />CORRECTION OF THE WELL LOCATION <br />Review instructions on the reverse side prior to completing the form. <br />Name, address and phone of the person claiming ownership of the well: <br />NAME(S): High Country Lamb LLC, c/o Tom Maneotis <br />Mailing Address: P.O. Box 156 <br />City, St. Zip: Oak Creek, CO. 80467-0156 <br />Phone 303 883-9512 <br />This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above. <br />This filing is made pursuant to C.R.S.- 37=90=143: - - - - <br />WELL LOCATION: Well Permit Number: 46214 Receipt Number:0392247 <br />County Routt Well Name or # (optional) <br />N/A N/A CO <br />(Address) (City) (State) (Zip) <br />SE 1/4 of the NW 1/4, Sec. 19, Twp. 4 ® N. or ? S., Range 85 ? E. or ® W., 6 P.M. <br />Distance from Section Lines: 2041 Ft. From E N. or ? S., 1872 Ft. From ? E. or ® W. Line. <br />Subdivision Name N/A Lot N/A , Block N/A , Filing/Unit N/A <br />The above listed owner(s) say(s) that he, she (they) own the well described herein. The existing record is being amended for <br />the following reasons: <br />® Change in name of owner E Change in mailing address ? Correction of location for exempt wells permitted prior to May <br />8, 1972 and non-exempt wells permitted before May 17, 1965. <br />Please see the reverse side for further information regarding correction of the well location. <br />I (we) claim and say that I (we) (are) the owner(s) of the well described above, know the contents of the statements made <br />herein, and state that the are true tom our knowledge. <br />Signature(s) of the new owner Please print the Signer's Name & Title Date <br /> Tom Maneotis, Owner <br />It is the responsibility of the new owner of this well to complete and sign the form. Signatures of agents are acceptable if an <br />original letter of agency signed b the owner is attached to the form upon its receipt. <br />For Office Use Only <br />State Engineer By Date