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'HIS FORM MAST BE <br />SUBMITTED PRIOR TO <br />THE EXPIRATION OF THE <br />'E RMIT. TYPE OR <br />PRINT IN BLACK INK. <br />COPY OF ACCEPTED <br />ST •TEME HT :;AILED <br />'EOUEST. <br />R OFFICE USE ONLY <br />Z. cty. yl~ <br />STATEMENT OF BENEFICIAL USE Of GROUND WATER <br />AMENDMENT OF EXISTING RECORD <br />PERMIT NUMBER <br />STATE OF COLORADO <br />~/ 55. <br />COUNTY OF ~ A-S rY/»~AS <br />ro ~~ ~ ,~ <br />THE AFFIANT(S) ../A7r~Os <br />whose mailing ~' <br />address is ~/~/rtW.9-/~ /I~.ZA <br />City ~~ fir n/ ~a ld ~i~ ~i <br />Isr •r[1 (xVl <br />RECEI <br />MPR 13 ? / <br />NSTAt EpEHC1~E~E4 <br />COLS <br />ti- <br />LOCATION OF WE/LtL <br />Cwnty ,S ~s a' /'4: hOrf7 s <br />~/ <br />Tr P. ~ ~ Rnq. ~~ ~ W ~ P.M. <br />IH oa SI IE o• N1, <br />being duly swom upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon; the well is <br />~ ~~s <br />- located as described above, at distances of -L-~ feet from the -section line and a R/f feet from the <br />lso~re ea seurnl <br />c' <br />~qST- section line; water from this well was first applied to a beneficiol use for the purpose(s) described herein on the ~G <br />ru at os w[ar) <br />r <br />jay of '-I~y 19~; the maximum sustained pumping rate of the well is (r" -gallons per minute, the pumping <br />r^•~ claimed hereby is _~ gallons per minute; the total depth of the well isfeet; th''e//average annual amount <br />of waterYto be diverted i/s' ~ ~~L acre-feet; for which claim is hereby made for ~ ~~Z 76~+c4SF ~/~~~ <br />• I.l SP (P M ~ npurp/ose(s); the legal description of the land on which the water from this well is used is <br />d-CT ~~ 7 ~~~ ~9 ~~ /'dUr ~/r~/ which totals <br />lpt~ <br />~~acres and which is illustrated on the map on the reverse side of this form; that this well was completed in compliance <br />with the permit approved therefor; this statement of brneficiol use. of ground water is filed in compliance with law; he (they) has <br />(have) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge. <br />Signature(s) <br />Subscribed and swom <br />to before me on this - <br />day of <br />19 <br />My Commission expires: <br />uu~l <br />FOT~11• ~Ua IIC <br />ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO <br />PURSUANT TO THE FOLLOWING CONDITIONS: <br />C~ <br />COLORADO DIVISION OF WATER RESOURCES <br />300 Columbine Bldg., 1845 Sherman St. <br />Denver, Colorado 80203 <br />FOR OFFICE USE ONLY <br />Coert Ces~ Ho <br /> <br />Wsll Uas <br />Dlsr. ~ Basin Man. Dh. <br />y D.r% c J. s~ <br />Prier. Mo. _ Day _ Yr. __ <br />GATE STATE ENGINEER <br />