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NOT1CCe OF INTENT TO CONSTRUCT MONITORING HOLE(S) sro� Please type or print legibly in black W& v gjp*s MAY 1 01998 N� STalr-Fh�lr1 F t- N ip Well Owner's NameCLI �E H /C.' L9Dl t�f it UJ l oCdtial: r .Section , Undowner's Name — L,4iyr> 5.�1/ueL� Townsh o� aM N, Rmge�EO PM O oa ef AAPLe Coige4 ( j lthf-70/Z County TEL-CyqL--7� MarTma Address: Wither, u a � � Subdivisron tj//t - Contact +�ctti1 Lvt _ - , l31)t . 199 Company L,E G Address P0 1 ri Holees)to be Constructed" Number - City,State, ZP \�� 1 � CT) �siated Depth, t- AWifer _ t y g 3 ` — — Purpose ofMoro torng Hde(s) A77= " uj Driller Liu. No.Cif applicable) on ACKNOWLEDGEMENT FROM STATE E GINEER` OFFICE FoR OFFICE USE ONLY 33479 PROCESSED BY DIV. CATTY /�-D, WE) 1. DATE Acxm0VV.E0GED 9R SAS MD GnouNo ELEv USGS MAP#_ CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE VVHFFtEN NOTICE OR ACKNOW LMGBRENT SHALL BE AVARASLE AT THE DRILLING S(TE. Notice waa prvvidad to the State Eu4heer at least 3 days prior to construction of monitoring&observation holc(s)- Coritruction of the holels) must be completed within 90 days of the date notice we13 given to the State Engineer. 'Coating and/or pumping shall not eXceesd a total of 200 hours unless prior wrkton approval it obtained from the State Engineer. Water warted ckwing testing shell not be used for beneficial purposes. The owner of the hotels) is re--ponsible for obtaining Permit(a) and comph►inv with an rules and regulations pertaining to the discharge of fluids produced during testing_ AN work must comply with the Water weir Construction Rultt, 2 CCR 402-2_ Minimum construction standards must be met or a variance obtained, Well Consvuctian and Test Reports IGYVS-311 must be submitted to this office hV the licensed contractor or authorized individual within 80 days of the completion of the work. Unless a welt permit is obtained. the hole(e) must be plugged and cesled within one (1)Year after eomtruction. An Abandonment Report (form raWS-91 must be submitted within 80 days of plugging a sealing. The owner of the holals) should maintain rocarda of water quality testing and submit this data to the State Engind0e upon request. The monitoring hole number. owner's etrueture name,and halo owner's nano and dmraea must no provided on all wON P"mit applieatlontz), well construction and abandonment reports. A monitoring hob can not be converted to a production water well(other than a recovery well) unless the hole Or well was origineRV constructed by a Gcmwe d well construction contractor. THIS AGx=WLWGEIWENT OF NOTICE DOES NOT INDICATE THAT WELL PO MIT(S) CAN SE APPROVED. A6 nor Conditions :CaLbFiADO DIVISION OF WATER RESOURCES-1313 SHUMAN ST-RM 821-DENVER-CO 80203 303-866-3587/FAX 303-ARR-15fIA TOTAL P.02