2011-11-09_PERMIT FILE - C1981012A ‎(3)‎

• Permit No: C1981012A
• IBM Index Class Name: Permit File
• Doc Date: 11/9/2011
• Section_Exhibit Name: EXHIBIT 11 WATER WELL INFO PART 3
• Media Type: D
• Archive: Yes

""""` COLORADO DIVISION OF WATER RESOURCES
THIS FOF;A MUST ^E
SUENRTED PR.OR TO
101 Columbine Bldg., 1845 Sherman St. ~
RE
C~~VEU
THE E]IPIRAnON OF THE
PERMIT. T'/PE OR Denver, Colorado 80203
PRIM IN BUCK INK.
~
STATEMENT OF BENEFICIAL USE OF
GROUND WATER
~ ~~
j ~
.
eMENDMENT OF EXISTING
RECORD t!ti'Rll
. srarE~~aB
to ~ 9s ~
PERMIT NUMBER ~'
RECEIVED
STATE OF COLORADO ~ ss MbY 31173
COUNTY OF ~- X# S ~ } N/ .
/Yl F~ S
A'ATEA ~raYtl RDES
STATE EllUIE2
THE AFFIANT(S)~ R NI_ ~ . /
G I , K P ~ ¢ B 1 l_ ~ ~i V/,_ ~ A k.. CT ~ ~. R Ttl caa
f X75 .. S, Q 1 Re h ~ d ~
whose address is-~~ ~/ v r /~T[3 ~/ ~~1} ~~D ,~~,~
being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon; the we!! :s
located in;the -g 1/ 1/a of the E 1/a of Section ~, Township ~ 3 -S• ,
(N. or 5.)
Range Ls~. J ~ ~ P.M. at distances of ~X •rTl feet from the ND 1z t ~I section line
(E. or W.) (North or South)
and~Tfeet from the ~/9 ~ r section line; the total depth of the well is -S ~ f et• water from this well
(Est or West) ~~ ~ ~~
was first applied to a beneficial use for the purpose(s) described herein on the' day of~ ~ 1 // nom;
th? maximum sustained pumping rate of the well is~gallons per minute, the pumping rate claimed hereby isJ~
gallons per11lIminute; the average annual amount of water to be diverted is~acre-feet; for which claim is hereby
~e for~7 ~ /~ S e. u n/~ S e ~ N L ~ I purpose(s); the legal description of the land on which the water
from this well is to be used
/oP.M.
which totals /. 3 77 acres and which is illustrated on the map on the reverse side of this form; that this well was completed
in compliance with the permit approved therefor; this statement.of beneficial use of ground water is filed in compliance with
law; he (they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his
(their) knowledge.
_. .~ _ _-: Ti.:

Subscribed and.sworn ~orbefore me on thi
of
19~.
My Commission expires: //- /- 73
(s~,D ~!~
Notary Public
ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF
COLORADO ON THIS DAY OF 19-.
ENGINEER
FOR OFFICE USE ONLY
Prior. Date, -
19
Well Use O
-'/ . _ I/.
t/.. Sec.
T. _ _, R. _, P.M.
Yield W.D ~ - ~ ~
cD. 3 6
WHITE COPY FOR DIVISION OF WATER RESOURCES
PINK COPY FOR WELL OWNER