Laserfiche WebLink
cwsst NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />o~rot Please type or print legibly in black ink - <br />Well Owner's Name Ctra~. Creel( £ V'cbr ~ao(d f~in~nS Cu.nduq~/ Location: ~l E %,. ~1 y/%<, Section )~ , <br />Landowner's Name Cn ink Crr~K7 Vt~br ~iu(d Y`Air\~..a ~n„pa..y Township IS N,(~I Ranged E/N L~ PM <br />Mailing Address: (Authorized Individual/or Driller) <br />Contact Twlm Cor.¢r ~ Chi f fnw nrvn -k..l Co rd •w-l~r <br />Company CrrpoL¢ Ct1rcL t; l/rc{ai C~okl Mrw`.. lln ...p~i <br />Address QC} BoY 191 <br />City, State, Zip Ulc}art CU ~Ug~t) <br />Phone 7 )9~[afS44oS5 fax No. 7/9~(n?>93Z5`{ <br />Driller Lic. No. (if applicable) <br />st+~ ro : GJ~~ - Is(~ <br />County -I e I fef <br />Subdivision u(L) <br />Lot ~) A , Blk ~ A , Flg AJ~Y~ <br />Hole(s) [o be Constructed: Number <br />Estimated Depth loo Ft. Aquifer <br />Purpose of Monitoring Hole(s) 111~n,')'or C ~.,,._d <br />Ltbk~r L~~~Is <br />Approximate Date of Construction 10 <br /> <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- <br />Dlv. <br />PROCESSED BV <br />WD BAS _ MD _ DATE ACXNOWLEDGED <br />GROUND ELEV <br />USGS MAP R <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPV OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIWNG SITE. <br />Notice was provided to the State Engineer ac lease 3 days prior to consuucuon of monitoring & observation hole(s). <br />Construction of the hole(s) must be Comple[etl within 90 days of Che dace notice was given Co the State Engineer. <br />Tesiing and/or pumping shall no[ exceed a total of 200 hours unless poor written approval is obtained fmm the State Engineer. <br />Water diverted during testing shall not be used far beneficial purposes. The owner of [he hole(s) is responsible for obtaining permit(s) <br />and complying with all rules and regulations pertaining to the tlischarge of Fluids producetl during testing. <br />All work must comply with [!te Water Well Constmcdon Rules. 2 CCR 402-2. Minimum construction standards must be me[ or <br />a variance obtained. <br />Well Construction antl Test Reports (GWS3~) muse he wbmi[tetl to [his office by the licensed convacior or au[hanzed individual <br />within 60 days of the completion of the work. <br />Unless a well permit is obtained, [he hole(s) must be pluggetl and sealed within one (l) year after construction. An Abantlonmenc <br />Report (form GWS-9) must be submitted within 60 days of plugging & sealing. <br />The owner of [t+e hale(s) should maintain records of water quality testing and submit this data co the Slate Engineer upon request. <br />The monitoring hole number, owner's structure name, and hole owner's name and atldress must be provided on all well permit <br />application(s). well construction and abandonment reports. <br />A monitoring hole cannot be converted to a production water well, except for purposes of rvmediation (recovery) or as a permanent <br />dewacenng system. if consvucted in accordance widt me Wacer Well Consaucdon Rules and parities of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL P13tM1T(S7 CAN BE APPROVED. <br />Additional Conditions <br />