HomeMy WebLinkAbout1.29 Well Change in OwnershipForm
'No.
STATE OF COLORADO For Office Use Only
GWS-11
I 6/1.()06
OFFICE OF THE STATE ENGINEER
818 Centennial Bfdg., 1313 Shannan St, Denver, CO 80203
Phone -Info: (303) 866-3587 Main: (303) 866-3581
Fax: 303 866-3589 h :J/www.water.state.co.us
CHANGE IN OWNERSHIP/ADDRESS
CORRECTION OF THE WELL LOCATION
I Review instructions on the reverse side prior to completing the form.
Name. add"il and;~ of the P!fS011 clabninQ ownershil! of the well:
NAME(S): _!fltvJ /£Jr t-l51fstl, ~
Mailing Address: "3 3 $ S-C!ouN-rf J?ol\-1> 3 I I
c1y, St Zip: New Ckrc..E Co fS / &,,4 7
Phone 'f 0 q 4 'ZL-8
RECE:VED
MAR l 5 2017
WATER RESOURCES
STATE ENGINEER
COLO
This form is filed by the named individual/entity claiming that they are the owner of the well pennitted as referenced above.
This filin is made ursuant to C.R.S. 37-90-143.
WELL LOCATION: Well Pennit Number: .;Z.<J't z._" z_ Receipt Number: ______ _
County ~ t\t2. Fl e ,,J) Owners Well Designation (optional) -------
3'38S-~NT'1 ~ 31( r\Jew A\\TLE <!-0 fJ&c.47
(Address) (City ) (state) (Zip)
SW1t4oftheSe 1/4,Sec. f3 Twp.lL_ON.or~ .. Range~OE.or~., S1xn+ P.M.
Distance from Section Lines: _____ Ft From D N. or 0 S., _____ Ft From D E. or 0 W. Line.
Subdivision Name Lot , Block__ , Filing/Unit __
The above listed owner(s) say(s) that he, she (they) own the well described herein. The existing record is being amended for
the following reasons:
Cir'Change in name of owner lir'Change in mailing address tJ Correction of location for exempt wells permitted prior to May
8, 1972 and non-exempt wells permitted before May 17, 1965.
Please see the reverse side for further infonnation regarding correction of the well location.
I (we) claim and say that I (we) (are) the owner(s) of the well described above, know the contents of the statements made
herein and state that the are true to m our knowled e.
Signatu ) of Please print the Signer's Name & Tdle Date
iJA.NIEL-£ • i~l~'1,S 'f hfMl-~17
State Engineer
~~~EPTEO i~s A c'HANGE IN O\VNERSliJP
. '' rVOR MAILING ADDRESS.
'3-fJ~--a
Date