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GWS -51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />3/2013 Please type or print legibly in black or blue ink or file online @ dwrpermitsonline(a state.co.us <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.water.state.co.us <br />Well Owner Name(s): Cripple Creek & Victor Gold Mine <br />Address: 100 North 3rd. Street <br />Phone (area code & no.): 719.689.4220 <br />Landowner's Name: Cripple Creek & Victor Gold Mine <br />Please check one and complete as indicated including contact info: <br />❑ Water Well Driller Licensed in Colorado — Lic. No. <br />❑ Professional Engineer Registered in Colorado — Reg No. <br />❑ Professional Geologist per CRS 34 -1- 201(3) <br />N Other - anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologist <br />Contact/ Company LMyers/ Cripple Creek &Victor Gold Mine <br />Address 100 N3rd Street <br />Cit State & Zi p Victor Colorado 80860 <br />J, , <br />Phone 719.689.4057 <br />Fax 719.689.3254 <br />Location: NW % NE <br />Township 15 ❑N EIS, Range 70 <br />County Teller <br />Subdivision: <br />Lot: <br />Section 25 <br />j7E r)!IW, 6 PM <br />Block: Filing Unit: <br />Site /Property Address Squaw Gulch <br />GPS Location in UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />the distance units, i— Zone 12 or 171 Zone 13. <br />Easting Northing <br /># of Monitoring Hole(s) to be constructed: 2 <br />Estimated Depth 400 Ft., Aquifer <br />Purpose of Monitoring Hole(s) Monitoring <br />Anticipated Date of Construction (mmldd /yyyy) 04/18/2014 <br />Print Name: sr-s Date Notice Submitted (mm /dd /yyyy): 04/14/2014 <br />(Must be at least 3 days prior to construction) <br />Sign or enter full name here: ZaLw- 252 Ma-ul <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />— MH PROCESSED BY <br />Div. WD BAS MD DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />1) 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 permit(s) and complying with all rules and <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 instructions, are found on the DWR website at <br />htta: / /www.water.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 owner's 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 />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON 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 PERMIT(S) CAN BE APPROVED. <br />(Use above space for labels or additional conditions as needed) <br />