HomeMy WebLinkAboutWell DocumentationState of Colorado Water Resources - View Well Details: Receipt 9500643 Page I of2
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htþ://www.dw¡.state.co.uVrtVcllPermitSearch/View.aspx?receipF9500643 U9t20r8
Form No.
GWS-11
08/2016
GOLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 Sherman St., Ste 821, Denver CO 80203
(303) 86e3581
dwmermitsonline@slate.qg.us
For Office Use Only
CHANGE IN OWNER NAMEIMAILING ADDRESS
PRTOR TO COMPLEnNG TH|S FORfrft, SEE NSTRUCTTONS ON REVERSE S|DE
INCOIIIPLETE, POOR QUALITY, OR ILLEGIBLE FORIIIS CANNOTBE PROCESSED AiIDVNLL BE RETURNED
Name. addreçs and phone number of oerson dalmlno ownershlo of the vræll permit
Name(s):lÂlllau Þar¡l Flrúl¡n fllll interesll
Mailing Address:Po f\¡r ß/,,
City, St. Zlp:lJ;f¡c /n llúSo
Phone: úfp tTfrffi Email:tth¡ti+mVA@ Ë/rt¿"'i
Well Permit Number: 234709 , Receipt Number 950Q649 Gase Number (optional):_
WEIL LOCAION: County:Garfteld Well Name or# (optional):
sitt co 81652TBDChair Bar Road
Street atWell Location C¡ty State zip
ECtred< if well address is same as owne/s mailing address
SE _ l/4 of the SE t/4. Sec. 17 ,Township 6.0 n N. orfl S., Range 92.0 fl E. or[lw.,6th P-M.
Distanæ from Section Lines: 131 Ft. ftom [ ¡f. orE]S. Line, 335 Ft ftom fi f. or[W. t-ine.
Subdivision Name (if appticable): Chair Baf Fanch , , Lot 6 , Block . Fiting/Unit
NOTE: lf changing/conecting the permitted location of a well, use Form No. GWS-42.
I (we) claim and say that I am (we are) the of the vvell permit described aboræ, know the contents of the statemenb made herein,
This filing is made pursuant to C.R.S. 37-90-143.and state that are true to my
the & Title
lMlev Paul Button lll3 ¡l¡zlt{
It is the responsibili$ of tlte new owner of this r¡rrell permit to complete and sign this form. lf an agent is signing or entering infuimation, please
see instructions.
Please allow 4 to 6 r¡t¡eeks br prccessing of this form. Thereafter, you can view or print the acæpted document at
htþ:/@utr.dwr.state. co. usMlellPermitSearch
Signature of DWR staff asa and/or Mailing Address.
For Staff Use Only
Staff Sþnature Date