2014-10-30_INSPECTION - M2004009

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FROM - DIVISION OF WATER RESOURCES 3036662223 NOTICE OF INTENT TO A. ` NSTRUCT M pww type. t" y in malt or COLORADO DMSION OF WATER URCES -1313 SK PHONE 3034*6 -=1 -FAX: 3 2N 4 Well Owner's Name, Address A PI e ILIr PJAC6 I [� If Y� uAF✓.� �'2�,�- C� Tawnship� Landowner's Name COMry g�� Supdrvutual, Lot, -T- Plaase check one and complete as indicated including contact inro: . C1 water Well DriNer Licensed in Colorado — Lic. No. ❑ Professional Engineer Register44 in Colorado — Reg. No. Professional Geologist per CRS 34-1- 201(3) j] Other - anyone cwrecily employed by or under the sopervis�on of a wriwo ariber. rq,swrea professional rxtowr orpmkiniondl wrgist J. _ Contact I Company Address 101 y � I @ 27 70; 4,;�- i T -013 P.01/01 F -465 . S V4 5' E V., Section 51 S. Range 65pEizW,1;,MPM Fig (as applicable) CPS Wwati4tt in UTM format (000nai): Set GPS unit to true noM. datum NA1383, and use meters for the= distance u jo. (]Zone 12 or MZone 13. Edsung Nortting -- f-aFMonitoring HaWs3 to 0e GensrracWr —� -- — — gstimasw Cepth 2�J Fk. Aquifer C,,,,," 111LIA& P of Moltim Ing Hole(s) 1906-� 9LWMA�. Anticipated Date of ConM► fiction. I D Dam Notice r:.f a (M� a s ast 3 ys iron w eonan+coott) ACKNOWLEDGEMENT FROM STATE ENC4NOR'S Fell OFF= UsE ONLY J 3AD9 - MH PROCESSED BY --� DIV. �_ WD Co SAS MI) DATE AcKNOw CONDITIONS OF MONITORING HOLE AFKN(JWLEAd A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEIIAENIT SHALL. AYAq TE DRILLING SITE. 1) Notice was provided to the state Engineer at least 3 day)r prior to consttived0n of moniccr on halo(s). 2) Constriction of the holds) must be completed within 10 fts of rite iota moults was givat ih $plte Engineer. Tative and/or pumping shall not exceed a lotel of 200 hours t,nkss prior wroan approval is 0018W imm 1110,:0i li inear. Water diverted during testing •shall nal tae ~Seel for beneficial purposes. The owner of tits hole(s) is responsible far abta,rong pamigsY wit complying with all rules and regulations pertaining to me discharge of flutes produced dumq T"Wo 3) All work Must comply wllf t the Water Well Constr uct)0rt Rules, 2 CCR 402 -2. Minimum cww4c*0 sonarO must be met or a variance obtained, Standa d parma apppu ton and worK report roans are found on the DM wamile at han, "w"am-MR R -M.na. Well Construction and Test RepaM (GWS31) must be completed for each hole drilled. The 6oeltsed contractor or 4i morizea individual must submit the c*nVm eel fonds 10 this offtce within 60 days of tgaawring 11010 completion• 4) Unless a well! permit is o4la ", pre hole(re) must bit pl aMpd and sealed within Arta (1) year after Construction. An Abandonment Report (form GWS4) must he submitted wkWn 60 days d ~g & sealing. T)te above MH aGC[t MaQeWM number, owners structure name, and owner's name and address must be prov,asd on all well pemat appliccauon(s)i welt fens =01`11 and abanoonmsnt reports. 5) The owner of the halals) shak maintain records of water quality testing and submit thin dataga tea Scare 9'Wnm upon 6) A MONITORING HOLI! CANNOT RE CONVF-R' OP TO A PRODUCTION WATER WELL, azc"fbwpl poses 0f rempdWftn (recovery) or as a permanent dewataring system, if conatructed in accordwIce with dw Water YWSCo,0119lr1IFtfan Rules and polies, of the State Engines. 7) IF HOLES WILL NOT Be CONSTRUCTED uNDER THIS NOTICE WITHIN 00 DAYS, PLEASE tNRI fli, �Ng MOLES CONSTRUCTED" ON A COPY OF THE ACKNOWLEDGED NOTICE WITH TtIE FILE NUMBER AND FAX THE COPY TO T"9 WV�'91QN OF WATER RESOURCES. ; THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERINT(S CAN BE APPROVED. G„ (Use abets t p & f labels or national conditions as nee4ad) Is:,'