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Form" STATE OF COLORADO <br />No. OFFICE OF THE STATE ENGINEER <br />GWS -1 t 818 Centennial Bldg., 1313 Sherman Si, Denver, CO 80203 <br />ft��ENE( 03) 866 -3581 Fax (303) 866 -3589 <br />rt t+ 2��,li -ii NGE IN OWNERSHIP /ADDRESS <br />DEC 2 • - RECTION OF THE WELL LOCATION <br />- 111VI5'NlEMIN 1.0 4 1 y ®6 0 L 6' <br />PUEBLO, COLORADO <br />Insert the Well Permit Number 0513 / q <br />Name. address and phone of the person claimiin 1 ownership of the weII <br />/E_ — <br />NAME(S) S 8 �AAL__ _ L 2 <br />Mailing Address 2.2 1 _2_ I JAA' �-- <br />Clt St. Zip _P_. kaf9.7—.C.12._-2 SSE ArTi4CY1M r7 <br />Phone ( 312.1 _ _/ ' — 2 / L7 )52R OrWeR IliveRS <br />This form is filed by the named individual /entity claiming that they are the owner of the well permitte <br />This filing is made pursuant to C.R.S. 37 -90 -143. <br />Owner's Well Designation./ 35 7. <br />_ P ai.r) GO WOOL_ <br />(Address) <br />(City) (State) (Zip) <br />JJLW V I/4 of the , 1/4, Sec. 35, Twp. 2. 0, N. or RI S., Range cy . ❑ E. or� W., 671/ P.M. <br />Distance from Section Lines <br />1078. Ft. From 0 N. or El S., 1g00 Ft. From 01E. or f W. Line. <br />o --_ � , Block FilingfUnit <br />Subdivision Name ,.. -.�,,, _� ---- ---- -� --- -� Lt '° <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 following reasons: g Change in name of owner R) Change in mailing address <br />0 Correction of location for exempt wells permitted prior to May 8, 1972 and non - exempt wells permitted before <br />May 17, 1965. Please see the reverse side for further information regarding correction of the well location. <br />I (we) claim and say that I (we) (are) the owner(s) of the well described above and that the commencement of <br />extraction of ground water from this well, lawfully made under the well permit, occurred on the date indicated, and <br />that the statements made herein are true to my (our) knowledge. <br />WELL LOCATION County _EVE81- 0 <br />Please print the Signer's Name & Title <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 />dAe z . <br />State Engineer <br />Signature s) of the new owner. � <br />By <br />d as referenced above <br />Fot Office Use Only <br />GI <br />For Office Use Only <br />o ,Slog* <br />RECEIVED <br />JAN 0 6 2004 <br />WATER RESOURCES <br />STATE ENGINEER <br />rec <br />0 . 1 ) <br />your well has an absolute water right, decreed <br />by the court and the well is not registered with the <br />State Engineer, enter the Water Court Case <br />Number / Civil Action Number and well number <br />as decreed. <br />Date <br />- - 20_ 3 <br />ACC`.171 Efi5 446,4,I9II OWNERSHIP <br />2- 17-x <br />Date <br />