DWR_3988299

• Permitno: 199147
• Receipt Number: 0407104
• Document Type - Well Permit: Change in Owner Name/Address/Location
• Annotated?: No

OORADO
CM
DivisionC L of Water Resources
DNR Department of Natural Resources
Change of Owner Name/Contact Information (for use by the well
owner or the well owner's attorney/authorized agent)
Summary Information Overview
Order Permit
21127 199147
Number: Number:
Date
10/22/2022 10:32:21 AM
Submitted:
eForm Change of Owner Name/Contact Information (for use by the well owner or the well owner's
Name: attorney/authorized agent)
Well Identification
• Permit No 199147
• Suffix N/A
• Replacement Suffix N/A
Well Address
• This is for information only and does not affect the permitted well location.There is no physical address associated
with this well
Owners and Agents
• Well Owners:
# Name Mailing Address Phone Email
1 HELM KAMP,ROBERT E 9838 E TOM TOM DR PARKER,CO 80138 7208420126 [e-mail]
2 HELMKAMP,BARBARA S 9838 E TOM TOM DR PARKER,CO 80138 7208420126 [e-mail]
Signature and Certification
1. I (we) have read the statements made herein, know their contents,and state that they are true to my (our) knowledge.
Pursuant to Section 24-4-104 (13)(a) C.R.S.,the making of false statements herein constitutes perjury in the second
degree and is punishable as a class 1 misdemeanor.
2. I (we) claim and say that I am (we are)the owner(s),an authorized agent of the well owner(s), or listed attorney of the
well owner(s) of the well permit described above, know the contents of the statements made herein,and state that they
are true to my (our) knowledge.This filing is made pursuant to C.R.S.37-90-143.
3. I (we) understand that filing a Change of Owner Name/Contact Information form is for contact information purposes
only.This action does not convey real property.
• l have read and agree to the Terms and Conditions listed above Yes