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GWS-SI NOTICE OF INTENT TO CONSTRUCT MONITORING HOL.E(S) 09 <br />ate _c tlt%, <br />3/2013 Please type or print legibly In black or blue ink or file online @ dwmermttsonlinjp_�Lt 10, us 14P ��, <br />COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST-STE 821-DENVER-CO-80203 <br />PHONE: 303-866-3581-FAX: 303-866-3589 WEB: www ater.state.co us <br />0 llvek�4 <br />Well owner Name(s): Location: Section <br />Township 5- 0� [-JS, Range ?4!�; ME r4l, &/.1/0PM <br />Address: <br />Phone (area code & no.): County <br />Landowner's Name. Subdivision ,100 <br />Lot Block Firing Unit :A0— <br />Please check one and complete as indicated Including contact Info: Site/Property Address Z�sfr ('Anr�Z <br />❑ Water Well Driller Licensed in Colorado - Lic. No. 4aeaz ;E/4 � 42� 15;r <br />❑ Professional Engineer Registered in Colorado - Reg. No. GPS Location In UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />❑ Professional Geologist per CRS 34-1-201(3) the distance units, f- Zone 12 or r- Zone 13 <br />9?1Other -anyone directly employed by or under the supervision of a licensed driller Easting J7_�� Northing <br />registered professional engineer or professional geologist 4 of Monitoring Hole(s) to be constructed: <br />Contact I Company 7= Estimated Depth/ 7YO "Ft., Aquifer z Aljz*z__ S_4 <br />Address Purpos. of Monitoring Hole(s) <br />City, State & Zip �VX_11;r,7* <br />Phone �M Fax :,#Tee (01 Anticipated Date of Construction (mm/dd/yyyy) <br />C4 ew C-9-1 <br />Print Name: Date Notice Submitted (mmlddlyyyy): <br />(Must be at least 3 days prior to construction) <br />Sign or enter full name here:_4� lZorl-rz- <br />A WLEDGEIMENT FROM STATE ENGINEER'S OF . FICE <br />FOR OFFICE USE ONLY <br />-MH PROCESSED BY <br />Div tQ WD BAS MD DATE ACKNOWI_EDGED. 43 <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE <br />f) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). <br />2) Construction of the hole(s) must be completed within 90 days of the date notice was given to the State Engineer. Testing and or <br />pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer Water diverted during testing <br />shall not be used for beneficial purposes The owner of the hole(s) is responsible for obtaining permits) and complying with all rules and lltl <br />regulations pertaining to the discharge of fluids produced during testing. <br />3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2 Minimum construction standards must be met or a variance <br />obtained Standard permit application and work report forms, including online filing InstructloiLs, are found on the DWRwebsde at <br />hctt)://%viyw.-,Yater.state.co.us. Well Construction and Test Reports (GWS-31) must be completed for each hole drilled. The licensed <br />contractor or authorized Individual must submit the completed forms to this office within 60 days of monitoring hole completion. <br />4) Unless a well permit is obtained, or variance approved, the hole(s) must be plugged and sealed within one (1) year after <br />construction. An Abandonment Report (form GWS-9) must be submitted within 60 days of plugging & sealing. The above MH <br />acknowledgement number, owner's structure name, and owners name and address must be provided on all well permit application(s) well <br />construction and abandonment reports. <br />5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request. <br />6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediation (recovery) <br />or as a permanent dewatering system, if constructed in accordance with the Water Well Construction Rules and policies of the State <br />Engineer <br />7t IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "No HOLES CONSTRUCTED" 0 A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERIVIIT(S) CAN BE APPROVED, <br />(Use above space foi labels or additional conditiow, as needed) <br />