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Form STATE OF COLORADO For Oh i ce Use Only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-11 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />1/2009 Phone - Info: (303) 866-3587 Main: (303) 866-3581 <br /> Fax: 303 866-3589 http://www.water.state.co.us RECE IVED <br />CHANGE IN OWNER NAMEIADDRESS <br />CORRECTION OF THE WELL LOCATION <br />011 <br /> APR 2 5 2 <br />Review instructions on the reverse side prior to completing the form. <br /> t SOURCES <br />Name, address and phone of Person claimin ownership of the well Permit <br />9 Z <br />WATtrR <br />STATE E INEER <br />- <br />NAME(S): tU?IALICA-6 Ol?V51 ?( V3 r <br />Mailing Address: (? . X A4 <br />City, St. Zip: TG[ fc : (b <br />Phone: ex' 1 %5 --7Y30 <br />E-mail (optional): -7-"LLLO POW <br />This form is filed by the named individual/entity claiming that they are the owner of the well permit as referenced below. This <br />filing is made pursuant to C.R.S. 37-90-143. <br />WELL LOCATION: Well Permit Number: G?3-] 'F Receipt Number: Cy54 9(Q3 Cas Number. <br />County I a V\ 0. Q Well Name or # (optional) <br /> <br />(Address) (City) (S tate) (Zip) <br />X1/4 of the 1/4, Sec. 2 u , Twp. 30 ® N. or 0 S., Range 9_ El E. or 0 W., _ - '0. P.M. <br />Distance from Section Lines: Gads R. From B11. or ? S., raI5 Ft. From ? E . or B W Line. <br />Subdivision Name Lot , Block , Fil ing/Unit <br />The above listed owner(s) say(s) that he, she (they) own the well permit described herein. The existi record is being <br />amended for the following reasons: <br />`Change in name of owner Change in mailing address ? Correction of location for exem <br />t well itt <br />d <br />i <br />t <br />M <br />p perm <br />e <br />pr <br />or <br />o <br />ay <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 1 (we) (are) the owner(s) of the well permit described above, know the conte is of the statements <br />made herein, and state that the are true m, r our knowledge. <br />Signature(s) o new owner Please print the Signer's Name & Title Da e <br />.-To-rY, 4ALL- - YVt / -7 <br />It is the 'responsibility of the new owner of this well permit to complete and sign this form. Signatures agents are acceptable <br />if an original letter of agency signed b the owner is attached to the form upon its receipt. <br />For Office Use Only <br />aCl.LV I'ED AS A CHANGE OF OWNI MW <br />AND/OR MAILING ADDRESS <br />L <br /> t <br />?? 2s <br />State Engineer By <br />ANIMAS6LAC1F-X <br />&c. a, v rr m - p/" 16 M - 3 7 <br />i