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yi- <br /> wRj-Zs.rr, STATE OF CCI.t?.ADO <br /> Index f4n _ DIVISION OF VATER FESOUPCt S <br /> OFFICE OF THE STATE ENGIr.iEt; <br /> It7Crtt. (J <br /> MAP AND STATEMENT F0:1 VATER WELL FILING "C 1 ' , <br /> chnchrrl by f O <br /> — - ,_...__.___- - F'tf^+IT hi11tPEA_�_ �,y __�'��''.,�_.r_ , ! {R y ..t•r Ct^ <br /> STATE (if CfKORA rN) ) S Y, LL-L('r .�Tj�`r.'t° G ( <br /> CLAIMANT Is) ) ; t. rti C r.11► {� { �'3� -,� of ,�,t. r , �'-� -e- - c�'` <br /> nf_1j"} <br /> twing duly sworn utmn (loth del,--;es and says that he (they) o , i,jr,-)*he owner owner i s1 of the Nt',l dnscrlL I hereon, the total num wr of t,rre5T. <br /> of land irrigated from this well is <br /> work was commenced on this well by actual constfuction on thn INDICATE PlELL LOC<1T110'; ON DIAGRA.'.' ; <br /> G� ''j� ' <br /> [ _-_day of ! I9tL; the sustained Nrxl r H <br /> yield from said well is gpm, for which claim is hereby mado I I I <br /> Ix i i i <br /> for l; 1.0_ r�G Purpose (s) +-- _ i -- <br /> I I i <br /> the average annual amount to be diverted is rri __ I _ _ I i D <br /> Ln <br /> acre-feet; this map and statement is filed in compliance with law; <br /> he (they) has (have) read the statements made hereon; knows the 1 <br /> - content thereof; and that the same are true of his (their) own <br /> knowledge. l <br /> 4'� I I I <br /> ' I I <br /> Signature(s) <br /> P SOUTH <br /> Address' <br /> WELL SHALL BE LOCATED WITH REFERENCE TO <br /> GOVERNh;ENT SURVEY CORNERS OR MONUtiIENITS, <br /> Subscribed and sworn to before me on this _ .day <br /> Of; SECTION LINES BY DI;TANCE AND BEAD;!^; <br /> of 19 ft. iron section ' <br /> (Ncxt!, or South) <br /> My Commission expires' <br /> (Seal) /'4J �^ ft. from section Iw: . <br /> (East or W st) <br /> Notary Publ;t <br /> r Ground Water Basinzt 4 f 7''1��► < ♦'Y�- __ <br /> WELL DATA Water Management 1 <br /> District .4 <br /> Date Completed �3 � �/ �/ / / Domestic wells may be located by the folio-.- <br /> x' Static Water Level 'r LOT A BLOCK <br /> Total Depth of Well �74 ! SUBDIVISION � r rr_ V�-te ' <br /> FILING a <br /> } <br /> ts, ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINFFR OF COLORADO ON THIS___, DAY <br /> OF _ __ . 19 <br /> .r <br /> STATE ENGINEER <br /> FORM TO PE k/.flE OUT IN QUAflftUMIC/ATE: KHITF I'(7l rn,,bt hn ri,n*.ig=-at c"y en hn^', 0 •4 <br /> t?^.-IfTF Af,D", FrN copies must be filed wit°t tf+s IST-19 F .t « r VA"On 20 s-r- rr•Rr IT-r-r it to 1 -•-- 1 .,7 f --;s <br /> niter r1w;ratien e"a of the permit.nr iW-,*.rT In vc-run:rf"*,, .r,-Y in f x f' , n.., ,-i yri,vA r.. ,... ,.. <br /> pq <br /> i <br />