HomeMy WebLinkAbout20150256.tiff Form STATE OF COLORADO For Office Use Only
No. OFFICE OF THE STATE ENGINEER
GWS- 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
11 Phone- Info: (303)866-3581 Main: (303)866-3581 ' F^,
7/2011 o/fie
CHANGE IN OWNER NAME/ ADDRESS
CORRECTION OF THE WELL LOCATION
Review instructions on the reverse side prior to completing the form.
Name, address and phone of person claiming ownership of the well permit:
NAME(S): Aurelio Gonzalez and Jose Gonzalez AS TO 50% Justin Chittenden
as to the remainder 50%
Mailing Address: P. O. Box 216
City, ST. Zip: Kersey, CO, 80644
Phone:
This form is filed by the named individual/entity claiming that they are the owner of the well permit as referenced below.
This filing is made pursuant to C.R.S. 37-90-143.
WELL LOCATION: Well Permit Number: :286001 Receipt Number: 3650450 Case Number: County: Weld
Well Name or# (optional):
TBD County Road 57, Kersey, CO 80644
NE41/4 of the SE41/4, Sec.10, Twp. 4❑ N. or®S., Range 64W❑E. or®W.,6TH P.M.
Distance from Section Line: Ft. From J . or❑S., Ft. From❑E., or❑W. Line.
OR: GPS well location information in UM/ format. You must check GPS unit for required settings as follows:
Format must be UTM, ❑zone 12 or Done 13; Units must be meters; Datum must be NAD83; Unit must be set to true
north. •
Easting Northing -
Subdivision Name Lot , Block , Filing/Unit
The above listed owner(s) say(s) that he, she, (they) own the well permit described herein. the existing record is being
amended for the following reasons:
®Change in the name of owner Change in the mailing address❑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 information regarding correction of the well location.
I I (we) claim and say that I (we) (are) the owner(s) of the well permit described above, know the contents of the statements
made herein, and state that they are true to my (our) knowledge.
Signature( of he ne- w,pwner Please print the Signer's Name &Title Date
� � lOfit +,.45t3
h
It is t e respcttsttr tity-cf.the new owner of this well permit to complete and sign this form. Signatures of agents are
acceptable if an original lelerof agency s gned by the owner is attached to the form upon its receipt.
For Office Use Only
ACCEPTED AS A CHANGE IN OWNER, -�
-JO/OR MAILING ADDRESS.
•
State ngrneer B Date
State of Colorado Water Resources - View Well Details: Receipt 3650450 Page 1 of 2
r: :J!Jf1i SiJ � 7iil.i1J J /
I r
1if: 1- _I\r ' JI )
Colorado's Well Permit Search
Well Constructed Help Last Refresh 8/4/201412.0303 AM
Receipt: 3650450 Division: 1
Permit It: 286001- - Water District: 1
Well Name/#: County: WELD
Designated Basin: Management District:
Case Number:
WDID:
[-] Applicant/Owners History
Date Range Applicant/Owner Name Address City/State/Zip
unknown Pr p5.44 GON/AIF/AHRFI1014 1O54 GON/AI F/504'. JIM IN CHI IT F N 50%.PO BOX/16 KERSEY.CO 80644-
[-] Location Information
Approved Well Location:
Q40 Q160 Section Township Range PM Footage from Section Lines
NE SE 10 4.0N 64.0W Sixth 2585 S 237 E
Northing(UTM y): 4464128.0 Easting(UTM x): 540094.6
Location Accuracy: Spotted from section lines
Physical Address Subdivision Name
City/State/Zip Filing Block Lot
Parcel ID: Acres in Tract: 38
[-] Permit Details
Date Issued: 06/23/2011 Date Expires: 06/23/2013
Use(s): DOMESTIC Aquifer LARAMIE FOX HILLS
STOCK (s):
Special Use: ISSUED UNDER PRESUME,'ION 3h-I IA
Area which may be irrigated: 1 ACRES
Maximum annual volume of appropriation:
Statute:
Permit Requirements: Totalizing Flow Meter Geophysical Log Abandonment Report
No No No
Cross Reference Permit Number Receipt Description
Permit(s):
Comments:
[-] Construction/Usage Details
Well Construction Date:07/18/2012 Pump Installation Date:
Well Plugged: 1st Beneficial Use:
Elevation Depth Perforated Casing Perforated Casing Static Water Pump
(Top) (Bottom) Level Rate
4635 115 35 75 18 15
Lic# Name Address Phone Number
Driller /I HAMACIIER.T R. BOX 86 SIMLA.CO 80835 719-541-2460
Driller 71 HAMACHFR AI AN RAY BOX 86 SIMI A CO 80835 /19.541./460
[-] Application/Permit History
Ownership Change 10/28/2013
Well Construction Report Received 07/23/2012
Well Constructed 07/18/2012
Permit Issued 06/23/2011
Application Received 05/26/2011
[-] Imaged Documents
Document Name Date Imaged Annotated
p I {_.- .I '1_- . • 11/26/2013 Nn
08/10/2012 No
�. .. . 07/28/2011 No
07/15/2011 No
http://www.dwr.state.co.us/wel 1perm i tsearch/V i ew.aspx?receipt=3 650450 8/4/2014
Satelliie
SATELLITE INDUSTRIES ACKNOWLEDGMENT
2530 xenium Ln N Order Number : SII-SO108129
Minneapolis, MN 554413627
UNITED STATES OF AMERICA Order Date: 09-Oct-2014
Phone: 763-553-1900 Shipping Date : 13.Oct-2014
Fax: 800-328-3334
Delivery Date : 17-Oct-2014
Customer: SIM33571 Customer: SIl133571
Sold To Ship To
Jose R Gonzalez Jose R Gonzalez
110 1st St 110 1st St
PO Box 296 PO Box 296
Kersey,CO 80644 Kersey,CO 80644
UNITED STATES OF AMERICA UNITED STATES OF AMERICA
Attention: 303-419-2357
Buyer: Jose R Gonzalez Ship Via/Camer: LTL-YRC ROADWAY/ ECH
Tel: 3034192357 Freight Terms: PREPAY AND BILL
Fax: Terms Location:
PO#: Shipping From: 105US/SATELLITE INDUSTRIES
Payment Terms: CREDIT CARD- PAID
Product Quantity Price Each Assembly Net Price Extended
Description Price
1431A 1EA 764.00 30.00 794.00 794.00
TUFWAY-C054 RBLU/RBLU
REG TANK ROTO BASE
Mount paperguard in standard position
Subtotal: 794.00 USD
Additional Charges :
S & H 256.00 USD
Tax 2.90% 30.45 USD
Sales Rep: TIM WHITE
Title : AM SOUTHWEST Total : 1,080.45 USD
Email Address: TIMW@SATELLITECO.COM
Phone: 800-272-3280
PAYMENTS NOT RECEIVED WITHIN THE PAYMENT TERMS SHOWN ABOVE WILL BE ASSESSED
A FINANCE CHARGE OF 0.85% PER MONTH ON THE UNPAID USD BALANCE
Terms of payment are subject to credit approval.
Taxes are subject to change at time of invoice.
Buyer grants Satellite a Purchase Money Security Interest in all the products secured hereunder.
Acceptance Signature Date
Order Number : 511-5O108129 Page 1 of 1 Printed. 10/09/20112:57:08 pn
Hello