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I,• It <br />Form STATE OF COLORADO For Office Use Only <br />No. OFFICE OF THE STATE ENGINEER <br />CWS-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 . hftp://www.water.state-co.us <br />CHANGE IN OWNERSHIP/ADDRESS <br />CORRECTION OF THE WELL LOCATION RECEIVED <br />Review Instructions on the reverse side prior to completing the form. MAY <br />Name. address{?and phone of the person claiming ownership of the well: g Zt7?8 <br />NAME(S): ' t "?Clln &l, Q . ereeM G..Y I S ATE ENG NEER S <br />COLO <br />Mailing Address: 1 0 6o 'y. La 3 5 <br />City, St. Zip: ( 01 GEC' t+PJA /?C (7({? Z <br />.ZL Phone (3"U-3) GI $ . 7 7 70 .fC 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: 0?01?561 <br />Receipt Number: % County [j7 ? ?'1 Well Name or # (optional) <br />598/ ir^ n On pot. f-ad L `1= Cd 00a 7 <br />(A ress) (City) (_S/t?ate) (Zip) <br />5e 114 of the-I& 114, Sec. ?, Twp. ? N. or X S., Range _._,? _ ? E. or XW, 6t- At o'ff- P.M. <br />Distance from Section Lines 7-00 Ft. From 0,N. or [I S., <br />----- Ft. From KE. or ? W. Line. <br />Subdivision Name Lot Block Filing/Unit <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 />L& Change in name of owner ? 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 t (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 />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 by the owner is attached to the form upon its receiot. <br />For Office Use Oniv <br />AS A CHANCE 03F DWNER$Hn, <br />AM" 1HAILINGADDRESS <br />State Engineer f y _Date''