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i <br />Form STATE OF COLORADO <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-11 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />6/2003 (303) 866-3581 Fax (303) 866-3589 <br />CHANGE IN OWNERSHIP/ADDRESS <br />CORRECTION OF THE WELL LOCATION <br />?1Z <br />Insert the Well Permit Number <br />Name add`re`ss and phone of the person claiming ownership of the 9 <br />NAME(S) <br />Mailing Address ??---??--? ?-1 9Q-, <br />City, St. Zip G ---may ?7 <br />For Office Use OnlyRECEMED <br />SEP 16 2003 <br />wSTATE N81NEFRs <br />CoLa. <br />?03914"1 <br />Phone <br />This farm is fled by the named individual/entity claiming that they are the owner of the well permitted as referenced above. <br />This filinq is made pursuant to C.R.S. 37-90-143. <br />WELL LOCATION. County Owner's Well Designation <br />I\U e, yr r '` '' {City }--^ (state) (zip) <br />(Address) 73 tt--??I 5?'9., <br />114 of theS 114, Sec.Z3, Twp. 5 ? N. or Y S., Range ? E. or LbJ W., P.M. <br />? N. or ?fl S., 3 _ Ft. From ? E. or ® W. Line. <br />Distance from Section Lines ?6?Q Ft. From <br />Subdivision Name, ?.Qa??MLA 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 <br />amended for the fallowing reasons: LAJ Change in name of owner ? Change in mailing address <br />? Correction of location for exempt wells permitted prior to May 8, 1972 and non-exempt welts permitted before <br />May 17, 1965. Please see the reverse side for further information regarding correction of the well location. <br />{ouer} knowledgabove, know the contents of the <br />my well <br />1 (we) claim and say h rent, lan(we) (are) the d state that they owner(s) of <br />statements mad <br />-Date <br />Please print the Signer's Name & Title _ Signature{s) of the new-owner- - - <br />IL Lk <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 receipt. <br />For Office Use Only AMEPMD AS A CHANCE I 0VftQlMW <br />MJDIOR MA[tJWj ADDPXM. <br />7 <br />OCT 21IM3- <br />Date <br />By <br />State Engineer