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COLORADO DIVISION OF WATER RESOURCES R �`` IV ED
TYPE OR 818 Centennial Bldg., 1313 Sherman St. . JAN 1 7 1985
PRINT IN BLACK INK
COPY OF ACCEPTED Denver, Colorado 80203 .WATER RESOURCES STATEMENT MAILED
ON REQUEST. STATE OF COLORADO AFFI T ENGINEFR
SS. COLO.
COUNTY OF ,_ Garfield _
_ STATEMENT OF BENEFICIAL USE OF GROUND WATER
AMENDMENT OF EXISTING RECORD
LATE REGISTRATION OWNER'S � E '/� C OPY
Y �ir_�E S (v
PERMIT NUMBER 127219 ..� LOCATION OF WELL
• Walter D. Dorman
THE AFFIANT(S) __ strilya L Tlnrann county 0nrfiP7d
whose mailing
address is 04 130 Road NW `,/, or the SE r, seriion 26
• City Glenwood. Springs, Colo 8160] Two _ 6S o , s • Rog. 88w I. 6th P M
1.'.•0 IzIP)
being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon, the well is
• located as described above, at distances of 3290 feet from the North section line and 3,730 _ feet from the
I u..o.,•
East section line; water from this wen was first applied to o beneficial use for the purpose(s) described herein on the 1.0411
rtt •n♦ ox '(5•)
e day of August , 19 84. ; the maximum sustained pumping rate of the well is , 11 , gallons per minute, the pumping
rote claimed hereby is - 11 gallons per minute; the total depth of the well i s 1 (35 -feet; the average annual amount
of water to be diverted is 1.2 acre -feet; for which claim is hereby mode for Domestic _
, purpose(s); the legal description of the land on which the water from this well i s used is
_Us - - a. a 5.. _ • • . ILL N. PAN, Ath PM of which
1.0 _acres are irrigated and which is illustroted 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 (hove) rent the statements made hereon; knows the content thereof; and that the some are true of his (their) knowledge.
LMPLETE REVERSE SIDE OF THIS FORM)
Signal urt.:rs !�'�• � . ! i ��. c9 4 vu1 -!mow
FOR OFFICE USE ONLY
' Subscribed and sworn
to before me on this . �/ el
day of _ ��
.; • 19 6
Cou.r Case No
My CommiSS ion exnires: _ • '' " , Prior
/,. A q 9 /.S�J
• didod D� _ 5 c,y. 23
ACCEPTED FOR FIL G B H E AT•E ENGINEER OF COLORADO
ro PURSUANT TO THE FOLLOWIN ONDITIONS: Sec..__
THAT THOSE CONDITIORS OF APPROVAL AS STATED ON TAE well us., — e. -
PERMIT ARE COMPLIED WITH.
• Disc _ Basin
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