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cws-sr NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />odor Please type or prinC legibly in black ink <br />Well Owner's Name I ~ CrccJ(4 ~cbr C-l~la rnrrl,n ,„ r,ry <br />Landowner's Name ~r,lpn )r (~irrck: 1 Vl~b. Mold Y`ltir\~..~ torn parry <br />Mailing Address: (Authorized Individuallor Driller) <br />Contact Tm~. Cumrtr ~C h f+ GSIUr o rim ~/ C ~ ~+~ <br />Company Cn00(p Grc/L 8 Ulclar C-+okl hlr (l+ ~r <br />Address AC) )~Y )9I <br />City, State. Zip (flt~orr Cry QC~B'6y <br />Phone -1 )9~f~X94as5 Fax No. 714~(~9325'-{ <br />Driller Lic. No. (if applicable) u ~~ <br />St~~ TO : U~ Mw • ISP <br />Location: rtlE %,~I~%a,Seciion )~ , <br />Township 15 N~ Range ~~ E, /~ , (off' PM <br />County Teller <br />Subdivision u~~ <br />Lot IJ R , Blk Iv A , flg ,U//3 <br />Hole(s) [o be Constructed: Number I <br />Estimated Depth` F7CO ft. Aquifer <br />Purpose of Monitoring Hole(s) R'lor<+~nr C~,,.~d <br />Approximate Date of Constriction /O~~.ou~ <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- <br />PROCESSED BY <br />DIV. WD BAS _ MD _ DATE ACXNOWLEDGED <br />GROUND ELEV USGS MAP iF <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIWNG SITE. <br />Notice was provided co the State Engineer ac least 3 tlays prior co conswcuon of monitoring & observauon hale(s). <br />Constrixtion of the hole(s) must be rnmpieted within 90 days of Ne date notice was given [o the State Engineer. <br />Testing antl/or pumping shall not exceed a total of 200 hours unless poor written approval is obtained from Ne State Engineer. <br />Water diverted during testing shall not be used for beneficial purposes. The owner of the hate(s) is resptrnsible far obtaining pertni[(s) <br />antl complying with all rules and regulations pertaining to the discharge of Fluids produced during testing, <br />Atl work must comply with the Water Wel( Consttuction Rules. 2 CCR 602-2. Minimum construction standards must be me[ or <br />a variance obtained. <br />Well Construction antl Test Reports (GWS-31) must be wbmitted to this office by the licensed conVac[or or authorized individual <br />within 60 days of the completion of Ne work. <br />Unless a well pertnic is obtained, Ne hale(s) must be plugged and sealed within one (~) year after construction. An Abandonment <br />Report (farm GWS-g) muss be wbmitted within 60 days of plugging & sealing. <br />The owner of the hole(s) should maintain records of water quality testing and submit Nis dares co the Seace Engirreer upon request. <br />The monitoring hole number, owner's structure name. and hole owner's name aM adtlress must be provided on all well permit <br />application(s). well carrsavcdan and abandonment reports. <br />A monitoring hole rannoc he converted to a production water well, except far purposes of remediadon (recovery) or as a permanent <br />dewacenng rystem, if consrrvcted in accordance wiN Ne Wacer Well Construction Rules and polkies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVEtl. <br />Additional CandiUOns <br />