HomeMy WebLinkAboutWell PermitForm No.
GWS-11
08/201 6
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATUFAL RESOURCES
1313 Sherman St., Ste 821, Denver, CO 80203
Main: 303.866.358,|
dwrpermitsonli ne@state.co. us
CHANGE IN OWNER NAME/MAILING ADDRESS
PRIOR TO COMPLETING THIS FORM, SEE INSTRUCTIONS ON REVERSE SIDE INCOMPLETE, POOR
OR ILLEGIBLE FORMS CANNOT BE PROCESSED AND wlLL BE RETURNEDQUALITY,
For Office Use Only
Name. address and phone number of Derson claimino ownershio of the well Dermit:
DEAN A. KARSTENSEN AND DENISE R. KARSTENSEN
3115 \,rJ. \*/lt r.root<A RD
YtoRlts, \ t- GO L+go
38G6684 Email: dean.karstensen@qmail-com
City, St, Zip:
Mailing Address:
Name(s):
Well Permit Number:66672-F
WELL LOCATION : County:Garfield
113 SHORE DRIVE, NEW CASTLE, CO 81647
Receipt Number:9502317a
Well Name or #RANCH WELL NO. 1
Case Number(optional):
Distance lrom Section Lines: Fl. From I tt. ot ! S. t-ine,
Address ai Well Location
P.M.
the permitted location of a well, use Form No. GWS-42
Ie.orffi W., SIXTH
SuMivision Name (if applicable): RIVEFVIEW BANCH
1/t ol lhe Sw %, Sec.12 , Township 6 [ tt. or ffi S. nange 92
NOTE: ll
Fr. From f] e. o, ! w. t-ine.
fl Cne* il well address is same as owner's mailing address
,Lot1 ,Block ,Filing/Unit
I (we) claim and say that I am (we are) the owner(s) of the well permit described above, know the contents of the statements made herein,
and state that are true to my (our)to C.R.S. 37-90-143.is madeThis
Please print the Signer's Name & title
DEAFT A. KAILSrE.N) S€f.]
DEnrrse- R. KARSTeNSE]h.)
Date
May27,2022
of the owner
It is the responsibility ol the new owner of this well permit to complete and sign this form. ll an agent is signing or entering information, please
see instructions.
Please allow 4 to 6 weeks for processing of this form. Thereafter, you can view or print lhe accepted document at:
http :/iwww.dwr.state.co. us^/VellPermitSearch
Signature of DWR staff indicates acceptance as a Change in Owner Name and/or Mailing Address.
For Staff Use Only
Stafl Signature Date
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