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GVVS-51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) 312013 Please type or print legibly in black or blue ink or file online @ dwflWrmitsonlI09A11akR.Q2.0 COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-STE 821-DENVER-CO-802b PHONE 303-866-3581 - --FAX: 303-866-3589 WEB: www.water state, coma S 10P 9e/;, 1Y Well Owner Name(s): .6,g,�tre_ Location: Zy act Township G!N OS, Range $?a U rJE rA, //PM Address:.— Phone (area code & no.): 0 "County ®' 71_ - Subdivision: Landowner's Name: 163 Jor.-P-27 '140" 6�2_f$-d Lot, Block* Filing Unit: _,ej�y Please check one and complete as Indicated Including contact Info: Site/Property Address .7 ❑ Water Well Driller Licensed in Colorado — Lic. No. 42i eakif Z ❑ Professional Engineer Registered in Colorado —Reg. No. GPS, Location in UTM format (optional): Set GPS unit to true north, datum NAD83, and use meters for • Professional Geologist per CRS 34-1-201(3) the distance units, I— Zone 12 or 17- Zone 13 f-D/Other - anyone directiv emninved by or under the supervision of a licensed dril er. Easting _?Z4 4K'? Northing _J'Y?- -41_ registered professional engineer or professional geologist Contact I Company Address City, State & Zip Phone Fax Print Name: Sign or enter full name N of Monitoring Hotels) to be constructed: Estimated Depth / Z*0 "Ft., Aquifer Allklje - Purpos of Monitoring Hotels) Anticipated Date of Construction (mm/dd/yyyy)Ze_&-_"/ Date Notice Submitted (mm/dcVyyyy). K14:111 (Must be at least 3 days prior to construction) AdPibWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE USE ONLY -MH PROCESSED 13Y Div 62 WD SAS MD DATE ACKNOWLEDGED CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT HE N 1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring& observation hotels). 2) Construction of the hole(s) must be completed within 90s of the date notice was given to the State Engineer. Testing and/or pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing shall not be used for beneficial purposes The owner of the hole(s) is responsible for obtaining permit(s) and complying with all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum construction standards must be met o obtained. Standard permit application and work report forms, including online fling instructions, are found on the DWR website httn: /twww.wnterstnte.co.us. Well Construction and Test Reports (GWS-31) must be completed for each hole drilled. The licen contractor or authorized individual must submit the completed forms to this office within 60 days of monitoring hole completion. 4) Unless a well permit Is obtained, or variance approved, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment Report (form GWS.9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number owner's structure name, and owner's name and address must be provided on all well permit application(s) construction and abandonment reports 5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediation or as a permanent clewatering system, If constructed in accordance with the Water Well Construction Rules and policies Engineer. 7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, -NO COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVIS N W THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) AN (Use above space for labels or additional conditions as needed)