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Home My WebLink About830131.tiff RESOLUTION RE: APPROVAL TO DRILL NEW WATER WELL AT KIOWA GRADER SHED SITE AND AUTHORIZATION TO SEAL OFF EXISTING WELL WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, it has been brought to the Board's attention that the existing water well located at the Kiowa Grader Shed site is polluted with sulphur , and WHEREAS, after study and review, the Board finds that chlor- inating the polluted well will not solve the problem, and WHEREAS, the Board deems it necessary to seal off the existing water well and dig a new water well at said site, and WHEREAS, the Board further deems it necessary to dig the new well deeper than the existing water well. NOW, THEREFORE, BE IT RESOLVED BY the Board of County Com- missioners of Weld County, Colorado that the drilling of a new, deeper, water well at the Kiowa Grader Shed site be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the existing water well at said site be sealed off. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 10th day of August, A.p.4 1983. /11c✓`,) 2t,.r� .-1r< ' i ,w U BOARD OF COUNTY COMMISSIONERS ATTEST: WELD LINTY, DO Weld County Clerk and Recorder and Clerk to the Bo Ch Carlson By: / 4 ( Ci.i ix. T /�il.1�LNJ D-puty Count erk J n . Martin, Pro-Tem APPROVED AS RM: EXCUSED (//h.� , ene R. Brantne r eorLoun Attu" �`�' Norman Carlson EXCUSED Jacqueline Johnson 830131 EGOo /7 t g 40.5 DAY FILE: August 15, 1983 1 h 'NRJ•5.Rev. 76 COwRADO DIVISION OF WATER RESOL 'ES 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 PERMIT APPLICATION FORM Application must be complete where ( ) A PERMIT TO USE GROUND WATER applicable. Type or ( ) A PERMIT TO CONSTRUCT A WELL print in BLACK FOR: ( ) A PERMIT TO INSTALL A PUMP INK.No overstrikes or erasures unless (X ) REPLACEMENT FOR NO. initialed. ( ) OTHER WATER COURT CASE NO. (1) APPLICANT - mailing address FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN NAME County of Weld Receipt No. STREET P.O. Box 758 Basin Dist. CITY Greeley, CO 80632 (State) (zip) CONDITIONS OF APPROVAL TELEPHONE NO. 356-4000 This well shall be used in such a way as to cause no material injury to existing water rights. The (2) LOCATION OF PROPOSED WELL issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water County Weld 1 right from seeking relief in a civil court action. SW / of the SE ', Section 6 Twp. 1 N , Rng. 61 W 6 P.M. W.S) iE.W) (3) WATER USE AND WELL DATA Proposed maximum pumping rate (gpm) 50 -- Average annual amount of ground water 3.5 3 to be appropriated (acre-feet): Number of acres to be irrigated: Less than 1 Proposed total depth (feet): 300 Aquifer ground water is to be obtained from: unknown Owner's well designation Small lawn, drinking/sani— tation, washing equipment GROUND WATER TO BE USED FOR: ( ) HOUSEHOLD USE ONLY - no irrigation (0) ( 1 DOMESTIC (1) ( 1 INDUSTRIAL (5) ( ) LIVESTOCK (2) ( 1 IRRIGATION (6) (X ) COMMERCIAL (4) ( ) MUNICIPAL (8) (X ) OTHER (9) Drinking & sanitation, washing APPLICATION APPROVED vehicle, irrigation of small lawn DETAIL THE USE ON BACK IN (11) PERMIT NUMBER (4) DRILLER DATE ISSUED Name Canfield Drilling Co. EXPIRATION DATE Street 111 West Street City Ft. Morgan, CO 80701 (STATE ENGINEER). (State) (Zip) 867-2943 729 BY Telephone No. Lic. No. I.D. COUNTY (5) THE LOCATION OF THE PI ''OSED WELL and the area on (6) THL ELL MUST BE LOCATED BELOW which the water will be used must-be indicated on the diagram below. by distances from section lines. , Use the CENTER SECTION (1 section, 640 acres) for the well location. 212 ft. from South sec. line + — H — T _ 4_ _ —T" _ 4_ _ + _ 4, (north or south) I I 1751 ft. from East sec. line I � --L 1 MILE,5280 FEET 1 (east ar wasp -I- + + f + ± + + I LOT BLOCK FILING r SUBDIVISION None NORTH SECTION LINE _ ± I (7) TRACT ON WHICH WELL WILL BE i I LOCATED Owner: County of Weld +NORTHT+ w _ + _ _ _ + _ _m + + 2.25 Will this be Z NNo. of acres z I m IO the only well on this tract? yes -h u I a • + — + (8) PROPOSED CASING PROGRAM I I-H I I I Plain Casing - 1.4 {- -I- 3— — + "- - — -m + + 6 in.from +1 ft. to 120 ft. I II 4 in.from 10 ft.to 240 ft. - I X I I 4Perforated casing • -E- - + I SOUTH SECTION LINE - T - I I I 4 in.from 240 ft.to 300 ft. + -Ir + + —I- 4 4 + -i- in.from ft. to .`t. I I I I (9) FOR REPLACEMENT WELLS givedistance and direction from old well and plans for plugging -1- - - f - 4_ - H- - 4- - + - 4- - + it 70' North & 19' East The scale of the diagram is 2 inches= 1 mile Each small square represents 40 acres. Old well to be filled according WATER EQUIVALENTS TABLE (Rounded Figures) to State regulation An acre-toot covers 1 acre of land 1 foot deep 1 cubic foot per second (cfs) . . .449 gallons per minute Igpm) A family of 5 will require approximately 1 acre-foot of water per year. 1 acre-foot .. .43,560 cubic feet . . .325,900 gallons. 1,000 gpm pumped continuously for one day produces 4.42 acre-feet. (10) LAND ON WHICH GROUND WATER WILL BE USED: 2.25 Owner(s): County of Weld No. of acres: SW3 SEA $6 T1N R61W 6PM Legal description: (11) DETAILED DESCRIPTION of the use of ground water: Household use and domestic wells must indicate type of disposal system to be used. Drinking & Sanitation, washing vehicles& irrigation of small lawn Septic & leach field (12) OTHER WATER RIGHTS used on this land, including wells. Give Registration and Water Court Case Numbers. Type or right Used for(purpose) Description of land on which used none none none (13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS TRU�T PP O _THE BEST O�HIS�LEbAE: SIGNATURE OFFAAAPPPLICCAANNTT(SS) J Use additional sheets of paper if more space is required. • • COLORADO DIVISION OF WATER RESOURCES TYPE OR 818 Centennial Bldg., 1313 Sherman St. PRINT IN BLACK INK. COPY OF ACCEPTED Denver, Colorado 80203 STATEMENT MAILED ON REQUEST. STATE OF COLORADO / SS. AFFIDAVIT COUNTY OF Weld )} STATEMENT OF BENEFICIAL USE OF GROUND WATER AMENDMENT OF EXISTING RECORD X LATE REGISTRATION PERMIT NUMBER LOCATION OF WELL THE AFFIANTIS) County of Weld county Weld whose mailing address is P.O. Box 758 SW ;4 of the SE /.. Section 6 y Greele , CO 80632 Twp. 1 N Reg. 61 _ W 6th P M City 1]r,ie) tnpt IN OR 5, IE on wi 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 142 feet from the South section line and 1770 feet from the is OP t.. OR SO VT I.) East section line; water horn this well was first applied to a beneficial use for the purpose(s) described herein on the ,.., cm Hilt was day of Spring , 19 52 ; the maximum sustained pumping rate of the well Tic 50 gallons per minute, the pumping rate claimed hereby is _ 50 gallons per minute; the total depth of the well is 60 feet; the average annual amount of water to be diverted is 3.5 ocre-feet; for which claim is hereby made for drinking & sanitation, washing lawn vehicles & irrigation of smallp rpo e(s); the legal description of the land on which the water from this well is used is SWty SEt $6 TWIN R61N 6pm of which than 1 Less acres ore irrigated and which is illustrated on the mop 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) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge. (CO LETE REVERSE SIDE OF THIS FORM) Signature(s) y/___ 19/G 5 FOR OFFICE USE ONLY Subscribed and sworn to before me on this .:f/ day of Court Cose No. My Commission expires: '... Prior. Mo. Doy _ Y. 9i3,ion,.r,r CO,. ACCEPTED F R FI I BY THE STATE ENGINEER OF •ORA00 PURSUANT TO THE OLLOWING CONDITIONS: Sec. IA. _ k. _. well Use Dist. _ Basin Mon D's _ ___—. DATE 57ATE ENG'NEER F' Well drilled by unknown Lic. No. Permanent Pump installed by unknown Lic. No. Meter Serial No. n/a LI Flow Meter Date Installed Owner of land on which water is being used County of Weld THE LOCATION OF THE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS THE AREA ON WHICH THE WATER IS USED MUST BE SHADED OR CROSS-HATCHED ON THE DIAGRAM BELOW. This diagram represents nine (9) sections. Use the CENTER SQUARE (one section) to indicate the location of the well, if possible. I I I I I I — + -- + — + — + -- + — + — I I I I I _i . — + — + + — + . — + — f — I I — NORTH SECTION LINE NORTH A + — + "21' z + + N J I rn n — Anki z I O I I .� I grAP O u in II r - + — + m- Q + + f- Lu X w t { SOUT'H SEC1ION LIME - + - + - + - + - + - + - I I I I I I THE SCALE OF THE DIAGRAM IS TWO INCHES E DUALS ONE-MIL E + — + — — + — + — ± — ( I --1) Mile ) WATER EQUIVALENTS TABLE (Rounded Figures) An acre-foot covers 1 acre of land 1 foot deep. 1 cubic foot per second (cfs) . . . 449 gallons per minute (gpm). 1 ocre-foot . . . 43,560 cubic feet . . . 325,900 gallons. 1,000 gpm pumped continuously for one day produces 4.42 ocre-feet. 100 gpm pumped continuously for one year produces 160 acre-feet. (WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER PINK COPY WILL BE RETURNED TO OWNER) W�2J•5-Rev. 76 �� CO �RADO DIVISION OF WATER; . RECEIVED 818 Centennial Bldg., 1313 Shertnan St., Denve fir _ r PERMIT APPLICATION FOEUIG 31 1983' A G 2 4 1983 Application must {�pttFCES be complete where (l() A PERMIT TO USE GROUND W I t �_. WATER RESOURCES applicable. Type or (X) A PERMIT TO CONSTRUCT A W €E°ENGII ME-EKINEEA print in BLACK FOR: (X) A PERMIT TO INSTALL A PUMP CCEP'• WAIL INK.No overstrikes or erasures unless 414 REPLACEMENT FOR NO. -. initialed. ( )OTHER WATER COURT CASE NO. (1) APPLICANT- mailing address FOR OFFICE USE ONLY: DO ITT WRITE IN THIS COLUMN NAME County of Weld Receipt No. 681(p ? / STREET P.O. Box 758 Basin Dist. I' CITY Greeley, CO 80632 (State) (Zip) CONPIJIONS OF APPROVAL TELEPHONE NO. 356-4000 This well shall be used in such a way as to cause no material injury to existing water rights. The (2) LOCATION OF PROPOSED WILL - issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water County Weld right from seeking relief in a civil court action. SW Y. of the SE ti,Section 6 GROUND WATER IS TO BE OBTAINED FROM THE Twp. 1 N Rng. 61 W 6 P.M. LARAI.IIE-FOXHILLS AQUIFER ONLY . iNs tE,W) DEPTH FROM LAND SURFACE TO THE BOTTOM OF (3) WATER USE AND WELL. DATA THE LARAMIE-FOXHILLS AQUIFER IS 500 FEET. CASING INSTALLED IN THIS WELL SHALL NOT Proposed maximum pumping rate (gm) .6436 15 EXCEED SIX (6) INCHES IN DIAMETER. ISSUED AS THE ONLY WELL USED IN A COMNER- Average annual amount of ground water .5 CIAL BUSINESS PURSUANT TO 37-90-105 (C) CRS to be appropriated (acre-feet): p Number of acres to be irrigated: Less than 1 feu oo Proposed total depth (feet): 300 OAP* 9/ t2,/$ 3 Aquifer ground water is to be obtained from: . J t,uk.te..:. Larimie - Foxhills Small lawn, drinkin /rani- • II. Owner's well designation $ tation, washing equipment f�, . eppf g �j;,; <. GROUND WATER TO BE USED FOR: c II. 7 ( ) HOUSEHOLD USE ONLY - no irrigation (0) ' 1 ( ) DOMESTIC (1) ( ) INDUSTRIAL (5) is SEP V i,,f I ( ► LIVESTOCK (2) ( ) IRRIGATION (6) 1983 1 (X I COMMERCIAL (4) ( ) MUNICIPAL (8) j 1 (X ) OTHER (9) Drinking & sanitption. washing APPLICATION APPROVED �tELEr U, coLo. vehicle, irrigation of small lawn DETAIL THE USE ON BACK IN (11) �� PERMIT NUMBER 817 (4) DRILLER SEP 201983 DATE ISSUED Name Canfield Drilling Co. EXPIRATION DATE SEP 2019$4 Street 111 West Street City Ft. Morgan, CO 80701 frA1 ) (State) (zip) a h7�2Gat. 867-2943 729 BY _ Telephone No. Lic. No. �i / /,. 1.D. / / -- Cj / COUNTY CY (5) THE LOCATION OF THE PP POSED WELL and the area on (6) TH°'NELL MUST BE LOCATED BELOW which the water will be used,mus . indicated on the diagram below. by a,._,aces from section lines, Use the CENTER SECTION (1 section, 640 acres) for the well location. 212 ft. from South • fsec.line + ___ -}- — -+- - + — - _4_ -- + -- _f_ — + _ -4- (north or south) I l 1751 East ..4----1 MILE,5230 FEET------p I ft. from_ sec. line L (east or writ) + T + + + + + + LOT _BLOCK FILING * I SUBDIVISION None +' — -4- - i NORTH SECTION LINE + - 1 I (7) TI3ACT ON WHICH WALL WILL BE I I k I r LOCATED Owner: County of Weld NORTH + z — — — + — g + t No.of acres 2.25 Will this be J I z I I co m I the only well on this tract? yes -4— ~ -fi w I + (8) PROPOSED CASING PROGRAM en I y I r ! Plain Casing - : - -I- -�- - + m + 1 61 in.from +1 ft. to 120 ft. I l 240 4 in.from 10 ft. to X ft. 4- - + SOUTH SEC ON LINE -` _4_ _ -1• Perforated casing I 1 4 in. from 240 ft.to 300 ft. + + + + -4- 4 4. 4•- + _ in,from ft.to `t. I I I I I (9) FOR REPLACEMENT WELLS givedistance and direction from old well and plans for plugging 4_ - -_ - +- - 4- - -i_ - +- - +- - 4-- — -� it: The scale of the diagram is 2 inches= 1 mile 70' North & 19' East _ Each small square represents 40 acres. Old well to be filled according It WATER EQUIVALENTS TABLE (Rounded Figures) An acre-foot covers 1 acre of land 1 foot deep to State regulation 1 cubic foot per second (cfs) ...449 gallons per minute(gpm) A family of 5 will require approximately 1 acre-foot of water per year. 1 acre-foot. . .43,569 cubic feet. ..325,900 gallons. 1,000 gpm pumped continuously for one day produces 4.42 acre-feet. (10) LAND ON WHICH GROUND WATE WILL BE USED: Owner(s): County of Weld No. of acres: 2.25 Legal description: STA SEA S6 TA R61VM6 - (11) DETAILED DEFRIPTION oPthe use of ground water: Household use and domestic wells must indicate type of disposal system to be used. • brjnkltig. & Sanitation, washing vehicles& irrigation of small lawn N,," .Septic-4 leach field i (12) QTHER WATER RIGHTS used on this land, including wells. Give Registration and Water Court Case Numbers. Type or right Used for(purpose) Description of land on which used none none none (13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS TRU TO THE BE T O HIS KNOWLEDGE. - _4L...... SIGNATURE OF APPLICANT(S) Use additional sheets of paper if more space is required. �. IMPORTANT INFORMATION FOR DOMESTIC AND LIVESTOCK WELLS FAILURE TO COMPLY WITH ANY OF THE FOLLOWING INSTRUCTIONS WILL VOID YOUR WELL PERMIT PLEASE NOTE CAREFULLY ANY CONDITIONS OF APPROVAL WHICH MAY BE ENTERED ON THE ATTACHED COPY OF YOUR PERMIT. These conditions must be complied with in order for the permit to be valid. For your information, a permit issued for Household Use Only may NOT be used Jor any out ide irrigation such as a lawn or garden,or for more than one singl family dwelling. YOUR PERMIT IS VALID FOR ONE YEAR FROM THE DATE IT WAS ISSUED. This means that the permit will ex ire and be of no force or effect unless the proposed well has bee constructed and a WELL COMPLETION AND PUMP INSTALLATION REPO T has been properly submitted to the Division of Water Resources by yourself or he well driller prior to the expiration date of the permit. This date may e extended by the State Engineer for good cause shown, if a written request is received prior to the expiration of the permit. The requ st should state why the well has not been constructed and the ength of extension desired. YOUR WELL MUST BE DRILLED ND THE PUMP INSTALLED BY A CONTRACTOR(S) LICENSED BY THE STATE OF CO ORADO. If you own and operate your own quipment, the well may be constructed by yourself in accordance with the Revised Rules and Regulations of the State Board of Examiners of ater Well and Pump Installation Contractors. ONCE WATER FROM THE WELL AS ACTUALLY BEEN PUT TO BENEFICIAL USE, THE REGISTRATION OF YOUR W LL WITH THE DIVISION OF WATER RESOURCES MUST BE COMPLETED BY YOUR UBMISSION OF AN ACCEPTABLE STATEMENT OF BENEFICIAL USE OF GROUND W TER. This registration is not a water rig t, only evidence that water has been put to beneficial use. Div sion of Water Resources tie 1313 Sherman Street Room 818 nver, Colorado 80203 866-3581 SUPPLEMENTAL INFORMATION The attached copy of your permit to construct a well is a VALUABLE DOCUMENT.The original permit is on file in the office of the Division of Water Resources. Additional copies may be obtained for a fee of $.50 per page. Any change of mailing address or ownership of the well permit should be reported in writing to the Division of Water Resources. If you did not indicate a proposed driller on your application, three copies of the permit are enclosed. One of these copies should be given to the driller you select and one to the pump installer. Please contact the Ground Water Section of the Division of Water Resources or your well driller if you have any questions concerning your well permit or any of the other forms. The following information is provided as an aid in completing the forms: The "maximum sustained pumping rate of the well" is the greatest stabilized pumping rate of the well with the permanent equipment inst lled.The "pumping rate claimed hereby" is the pumping rate approved your permit, or the maximum sustained pumping rate, whichever is less.This is the pumping rate for the normal operation of the well. WATER EQUIVALENTS TABLE(Rounded Figures) An acre-foot covers 1 acre of land 1 foot deep. 1 cubic foot per second (cfs) = 449 gallons per minute (gpm). 1 acre-foot = 43,560 cubic feet = 325,900 gallons. 1,000 gpm pumped continuously for one dayyroduces 4.42 acre-feet. 100 gpm punted continuously for one year produces*0 acre-feet. 72 ' r ! �' U rl l'. .! 't V • 3M MI ,;C;;t •TrEU I•Callit. °;: • 30 DA' . OF t:.•. P II ON r•.,;n .. OF' t WORK UEsCRIB IERE- U? ".C4.)! •�G: �. 01" (PE OR PRINT IN r :,C V _L CC .' is T IOt •'•D=''is•.,? ;i''=; ._,AT: im RE. .M i IN' . WELL' .:INER C• . ..._...'__ ••1`1 - -- —.. %of the ',4 of f-e.c. ..., _ ADDR'. . .'.0. ?< 7:. ;Ili • T. _— .. DATE 1 •PLETED , 19 HOLE DIAMC .R V ELL LCG •.�in. fi.tm t• to 1.7'• ft. 1'dater /. From --o Type and Color of Material Loc. in, from l�t to ft. 0 tr -' 1 _______ in. from to ft. . ; E` c F„i1ri .. 'And ''.�,...� • . Zr, ..:!?•',.:' CAGING RECORD: Plain C�.,ing I r .. :.'. rI':. .1 .nx' D ::• Co . .:: •,it t i:;Ice fir... i Size " & kind __- . from . • to ___4.11._ ., z ' lir'' .: t....1.. ...; I el:. r•.; ....1 J.° 'ck clay Size _& kind from to h ' Size from to ft . .. r.._. . . _. � t•' east +�3at � . ;:�c & kind flit.1 .',.j '•±i•..2 t. • .. i.:•12" c '.`.-t is :Cc 171.! , ..r,. i .. . !' Pt r otar d Casing `�C� , I �. • a .'-:‘.. ..i.:^ I Size & kind from to ft - :•):•a ..► :,' ;id viidoi•' V; '• ^' ::1e Size rx k,i id— _ from to f;. ..... e • C,y .'. 10 '•: . ~r' t'it . ..r-y • Size _ & kind _ from to ft. i'' GROUTING REM ID ll: '• . .t;1' Material �. - L''''; ' :Az ?..• I..tervals "i:'• .° 1::.-J . :. .;e 1-':l xe.c • • Placement Method pc•. '.'a:,.f: 2.M) "!!e..: I . Cfl"VEL PACK: Size i .'(.9:. !O !'i::1t • pf'7^F,'1 0 nre-1 — :18 . !n', rod: interval _tal . .) a"At . •.,.'.)p . :.f; :9 ; .3 .x: !s,; .1c: '� -Ltcn. ;,1% s •� ., TEST DATA P • ' ';‘•'i stro:.i; 41 : ..•~2 rock Date Tested ' "' 19 ~ t s!" .,o ._:'O .ir;. ►: :;;i.t:?:y cs,. 1.1h Static Water Lev:I Prior to Test 1: ,., ft. .,.t 9C., ..ot' 15;1...1,. Type of Test Pump • -.!:m.k:, : 31er Length of Test _ , Sustained Yield (Metered) 2ff. our-.1 _- - TOTAL DEPTH '' c"' Use addition I pages necessary to ..omplete log. Final Pumping Water Level 12-v _ • . / . ._ 'UJ\IP i 'S TALLATIC,N FIE O /— • ?I'i f, :. 'ump ; Make �u -._ i, ,s;a '4' ,; , 1 1•yp SU - — i ,STI ?a ',:.:,,:::;.s. f; � 'owered by --- .. - - HP 'ump aerial No. ( •'= _ ( ;s ` a Motor ;serial No. : :; WATER v> TABLE )ate Installed 11- w I.w 1; iS in 'ump Intake Depth :::60' '° w F tic - - - x -: K 3emarks - - - - - r - - -- • � �'s ,. _ ? z -r"i • �. .w a i .1-• r • ., 12' ';. Z O � - a 1t1 .N. ‘ :i /�i ;3 � ,* '� "c , Fy JELL TES.T DATA WITH PERMANENT PUMP }— R 4' .'t )ate Test Id is -�:�. ' ..l •" -4. �:• CONE OF ;vatic Water Level Prior to Test '••j ' o • DEPRESSION' _ength of Test 2 Hours W is stained yield (Metered)_ ;• s:- ' '�-` GPM i l ' ':;mping W,'ater Level ,'`=' i.. 'LJi`Mti' • • �i , i i e m a r k s - 1 ,z;: A . ,lift.:: .: I 4 CONTP ACTORS STATEMENT The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or pump istallation described hereon; that he has read the statement made hereon; knows the content thereo;, and that the same is true of his own knowledge. Signature it : :;1"':11 rt:' , !JAI- }-,Y 5].:3 License No. State of Colorado, County of w.t•" SS Sul.•scribed and sworn to before me this day of , `19 . My Commission expires: Notary Public • I i FORM TO BE MADE OUT IN QUADRUPLICATE: Mil r E FO'sb1 must L•: an original copy on cinch sides and signed. . 1 WHITE AM' GREEN copies must be filed with the State Eno,neer.Pio.:i COPY ;s for ,he Owner and YELLOW COPY is for the Driller. : 7 • / 1 _ 1- i L • .5 Hello