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t <br />7( <br />Form <br />STATE OF COLORADO <br />For Og ,u- swrily <br />No. <br />OFFICE OF THE STATE ENGINEER <br />V :L-Y <br />GWS -12 <br />1313 Sherman St., Room 821, Denver, CO 80203 <br />6/2012 <br />Main: (303) 866 -3581 Fax (303) 866 -3589 <br />DWR Website: www water.state.co.us <br />SEP 16 2014 <br />Email to: dw anitsonline state co.us <br />JER RESOURCES RECEIVED <br />TAT NEER <br />REGISTRATION OF EXISTING WELL W <br />Review form instructions prior to completing form <br />COLO <br />SEP 1120# <br />NAME & CONTACT INFORMATION OF WELL OWNER: <br />Name( -) f <br />n e -STI H .a G oak <br />omsrotlatarr <br />PUEetO,COLORW <br />Mailing Address <br />IoLS o�c�n�e <br />ty: <br />'Tpy'e At <br />State: <br />- <br />Zip Code: <br />0 <br />Phone No. with area code <br />Email <br />// - ro <br />/ <br />WELL LOCATION County: ?u 6 O Well Name(optional): <br />u,91 /4i pl yl iIt 1 '�7 / °cam 72 ,/ e (fo g I o ( 9 <br />(Address) (S/t�at�e�),/ (Zip) <br />�(� J��((city) <br />16 1/4 of the /r U 114, Sec 3& L11 N. or CXS., Range I k ® E. or W., 1 h P.M <br />, /(p <br />t7Twp <br />Distance from Section Lines Ft.�fv� N o �S. Line, 31X Ft ® E. or ® W Line. <br />ATTACH A COPY OF A CURRENT DEED FOR THE SUBJECT PARCEL <br />Subdivision Name `J' D r Lot Block Filing /Unit <br />Optional- GPS location information in UTM format The following GPS settings are requlAq e <br />well Easting <br />Format must be UTM, Units must be in meters. Datum must be NAD83. Unit must be set to true <br />north. IC Zone 12 or IQ Zone 13 <br />Was GPS unit checked for above items? 17 YES rl NO Northing <br />The well has historically been used for the following purpose(s) <br />Water first used beneficially by the original owner for the above described purposes on (mmlddtyyyy) <br />The total depth of this well is feet. <br />i <br />The pumping rate of this well is 5 gallons per minute. <br />The average annual amount of water diverted is 1 acre -feet. <br />The lawn and garden irrigated (watered) by water from this well is 0 M Acre or M Square feet. <br />Number <br />The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant to <br />C.R.S 23- 3- 104(13)(a). I have read the statements herein, know the contents thereof, and state that they are true to my knowledge. <br />Si or enter name of Well Owner(s) <br />Print Name and Title of Well Owner(ss))% <br />Date (mm /dd /yyyy) <br />For Office Use Only Transaction# 3686607 31 <br />((��/ � 11 -11- Date, 9f18C1014 12 28 31 PM <br />WE "" "`�� ����1��^ Transaction Total $10000 <br />Y (� (� �"-' 1� CHECK #f987 $100.00 <br />WR _ <br />CWCB C � Iv t-119'681oL <br />� l�N E Sb T �oS3 <br />AQUA 112, (55 Basin MD <br />1 o <br />MYLAR Div WD <br />