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Gr,s NOTICE OF INTENT TO CONSTRUCT MONITORING HOLES <br />Please a r print legibly in black or blue ink or tale oniine �cfr i cpn; re JSF 'c cC �s'� <br />('!p- Pin �3 Y @ <br />COLORADO C VISION OF WATER RESOURCES -1313 SHE11MAN ST-STE 821- DENVER- 0-3wik 5 <br />HONE 3034868-3581 —FAX 303 6 _358QVqEB <br />Well Ovmer Harrie(s): The Eureka <br />Address 48 i S Sand Trap Lane <br />Phone (area code & no.): 719-547 - <br />Landowner's Name: USFS _ <br />Please check one and complete as i <br />C) Water Well Dn ler Licensed in Colo <br />Professiorai Engineer Re jistered + <br />❑ Professiona Geologist par CRS 34 <br />f Other - anyone dire^iy employed by a <br />registered profess oral crg rear a profe< <br />Contact Company --- Dnif(ng.In <br />Address 250 V\r Berger Lane _ _ <br />C +iy State 8 Z!p alt Lake <br />Phone 801- 270-2157 <br />lining Company, LLC Location: SE % SE /. Section 3 <br />o_ueblo West CO 81007 awns= 11 :3N -!,IS Range 82 f-?E -jlN 6th PRA <br />838 ounty Lake <br />3ted including contact info: <br />- L+c No <br /><;oiamdo -Reg. No <br />1- 201(3) <br />under the s6-l:en•as,on er a tcsnsed drdl- <br />1n2, geologist <br />UT 4107 <br />Fax 801 -281 -2880 <br />Print Name: Jim Fine Managing <br />Sign or enter full name here:_, i <br />Dlv - - -- WD �•� <br />A COPY OF THE WRIT <br />j 1) <br />Notice was provided to the Sta <br />(; 2) <br />Construction of the hole(s) ML <br />pumping shall not exceed a total <br />Shall not be used for beneficial p <br />regulations pertaining to the disc <br />3) <br />All work must comply with the <br />cbiained Standard permit appif <br />lilt," Vtl <br />_,ntractor or authorized ind!vtdu <br />4) <br />Unless a well permit is obtain <br />( <br />construction. An Abandonmi <br />iconstruction <br />ad:nowiedgement number. own <br />and abandonment <br />5) <br />The osner of the hole(s) shat <br />F. <br />A a90NITOR(NG HOLE CANN <br />or as a permanent deveaterinl <br />Englne °r <br />THiS <br />Lot: n1a 610cl< n/a Filing Unit ZV- <br />ilte/Property Address CO State vy_82 1 st sw tch back <br />East side of Independanoe Pass <br />3P5 Location in UTM format (optional): <br />3el GPS unit to true north. datum NA083. a d use meters for <br />he distance units Tone 12 or Zone 13 <br />Easung Northing <br />V of Monitoring Hotels) to W constructed: 5 <br />Estimated Depth 1.0-0-017t., Aquifer None <br />Purpose of monitoring Holes) Core dnlling unpatente <br />claim site exploration for precious metal content <br />06/0112015 <br />Anticipated Date of Construction (mm/ddfyyyy) <br />Date Notice Submitted (mm /ddiyyyy): 1 011212014 <br />;Must be at east ; days prior to construction <br />4CKNOWLEDGEMENT FROM STATE ENG'NEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH PROCESSEDBy ; <br />LS IM0 DATE ACKNCUVLL-DGED — <br />ONDITIONS OF MONITORING MOLE ACKNOWLEDGEMENT <br />EN NOTICE OR ACKNOVIrt-EDGEMENT SHALL BE AVAILABLE AT THE DRILLING SiTE. (' <br />r <br />s Engineer at least 3 days prior to construction of monitoring 5. observation hotels). <br />t be completed i;,Athin 90 dons of the data notice was given to the State Engineer. Testing and'or <br />if 200 hours unless pnor written approval is obtained from the State Engineer Water diverted during testing !; <br />rposea The o -.vrer of the hote(s) s responsible for obtaining permits and complying with all <br />rotes and �j <br />arge of Fluids produced during testing <br />Mater Well Construction Rules, '2 CCR 402 -2 Minimum construction standards must be met cr a van ante <br />iton and work report forms including online rtI(ng instrucitons are found on the DWR website at <br />fl Construction and Test Reports (G4NS -31) must be completed for each hole dntlt?d The licensed <br />I must submit the completed forms to this office within 60 days of monitoring hole coripletwn <br />J, or variance approved, the hole(s) must be plugged and seated within one (1) year after <br />1t Repot i (form G'�`�5 °} mum be gubmffted vrithin 60 days of plugging a sealing. The above BAH <br />cool <br />!r's structure name and owner's name and address must be provided on an we 1 permit apptrcattonis) ' <br />aports <br />i <br />maintain records of wai,w quality testing and submit this data fig the StateEngineer &upotn n (raco enl) <br />iT BE CONVERTED TO A PRODUCTiON WATER WELL, except for purPos <br />system, if construc�od in accordance with the water lNell Construction Rules and policies of the State <br />I <br />{ <br />?EfuiENT OF i!O,ICE DOES NOT iNDiCATE THAT WELL PERMIT(S) CAN BE APPROVED <br />(Use above +Race for :abels or additional conditions as needed, <br />