I _________________________________________________________________ do swear and depose as follows:
1. I am the owner of a well located in the _________ of the _______ of Sec. ____ Township _____S/N (Circle one.), Range ______ E/W (Circle one.), well permit no. ________, WDID no. (Only if decreed.) ____________. The well is permitted for _______ gpm/cfs (Circle one.), for ________________________________ uses.
2. I have been using the well identified above as the water supply for the following uses listed in Section 37-92-602 (1)(b) or (1)(e), C.R.S.:
a. Ordinary household uses in ______(No.) single-family dwellings;
b. The irrigation of ______(Area/ acres) of vegetation.
c. The watering of domestic animals ____yes / ____ no. since prior to May 8, 1972.
3. Per historical considerations of drought and or rainfall, I will continue same uninterrupted usage of said well respective of.
4. In good faith I retain the right to continue into the future, as in the past, the handling of my own metering, measurements, and operation hereon.
5. I understand the Division Engineer seeks to abandon all but some water rights, and limit the decreed capacity to _____ gpm/cfs, associated with this well in the next decennial abandonment list pursuant to Section 37-92-401 (2)(b).
6. Please know that it is not my intention to abandon my right to use said well.
7. I hereby attest that it is my unequivocal intention to exercise my right to continue uninterrupted usage of said well, as I, owner of well, deem necessary.
8. Furthermore, I hereby demand that no entity, including state, county, city, town, township, or school district, shall encumber same usage of said well, for any and all successors-in-interest.
___________________________ _________________________
Print Name Affiant (Signature)
_________________________________________________________________Address
___________________________________________________________City, State, Zip
Subscribed and sworn to before me in the County of __________, State of ___________,
This _________day of _____________, 200__________
___________________________________________________ My commission expires:________________________
NOTARY PUBLIC