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' I.VLUKAW UIVIJIUIV Uh WAItK KtJUUKI,tJ <br />THIS FORM YUST III IIIIII I II IIII III <br />SUBMITTED PRIOR 101 Columbine Bldg., 1845 Sherman St. Doc Date:12111/2001 <br />THE EIPIRATION O <br />PERUrr. TTPE oR 999 Denver, Colorado 80203 V OL- <br />PRINT IN SLACK INIa. • • ~ V LI ~ L•Y <br />STATEMENT OF BENEFICIAL USE OF GROUND WATER <br />AMENDMENT OF EXISTING RECORD MAV ~ i'j$ <br />• PERMIT NUMBER ~~~ ~ ~ `~TFR a[EOeR00 <br />Sici[ F~~ <br />STATE OF COLORADO ~ ~j/~ ~~~~jg~ ~ ~~ _ wA~ <br />~ /~./i i"y /J / Si <br />COUNTY OF ~~/ ~~ /N~~ _~~~~ !/ <br />THE AFFIANT(S) ~'{'~ ~`t ~ ~~~~ ~• 'f •~ "` ~ <br />whose address is ~~"16 `'~~u. ~~~ I ~.rf~" "`~ G. c ~~: <br />being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon; the well is <br />located in the ~~' ~• 1/4 of the ~ =~ - I/4 of Section J ° ,Township a ~ •r <br />(N. or 5.I <br />Range ~~ L~ `~~ P.M. at distances of ~ 3' feet from the N' section line <br />(E. or wJ (NOnn or South) <br />and 2 /~ feet from the L~ section line; the total depth of the well is ~~' ~ feet; water from this well <br />(East or WesU <br />was first applied to a beneficial use for the purpose(s) described herein on the ~ Tz day of /i '~ , 19 ~ J <br />"•e maximum sustained pumping rate of the well is ~~ gallons per minute, the pumping rate claimed hereby is ~~ <br />allons per minute; the average annual amount of water to be diverted is ~ acre•feet; for which claim is hereby <br />~de for ~ Jii~tC/'~`F6 ~' °/~~f° ~ purpose(s); the legal description of the land on which the water <br />from this well is to be used is L "~` /- ~ ~ ~i c %.s.cr1 /~/b,rr T'`~ c7' ~/'T~-~F~~-~r-<; G ~! <br />which totals ~- ~ ~~~acres and which is illustrated on the m ap on the reverse side of this form; that this well was completed <br />in compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with <br />law; he (they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his <br />(their) knowledge. _ <br />Subscribgg.anD.sworn to_before me on this 18th day of <br />- M&Y , 19 73 . <br />~srch 9, 1976 <br />My Commission expires: <br />(se.n --~~ <br />K~ ~-Y''d~~`J <br />~ Notary Public <br />ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF <br />~LORADO ON THIS DAY OF 19_. <br />~~. <br />~INEER <br />FOR OFFICE USE ONLY <br />Prior. Date. 19- <br />Well Use O <br />I/. -I/. _I/. Sec. <br />T. _ -. R. - _, P.M <br />Yield W.D <br />~D. 3 <br />Inde• <br />WHITE COPY FOR DIVISION OF WATER RESOURCES <br />PINK COPY FOR WELL OWNER <br />