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cws-st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oaiot Please type or print Iegibiy in black ink <br />Well Owner's Name LlrjPpJr. Crdol( E Vl~b~ (7~o(d min,nS Cup...dan.~ <br />Landowner's Name (J'rrlpolc ~«,K r VI~'d. ciuU Y'Air~.", In.w pa...y <br />Mailing Address: (Authorized IndividuaUor Driller) <br />Contact ! ~ m.., Co,ur / C h ~' c~vr o not .(d/ [` .~ ./o <br />Company CrrpoLe Cr<c~ sr Ur~h< L~olrt hl, ..u,Y(4.1en(I~r <br />Address Ao BoY 191 O <br />City, State, Zip _Ulc}+>rr CCU B~S~U <br />Phone ~ 19~(aX9 gos5 Fax No. 719~(„g9325'-j <br />Griller Lic. No. (if applicable) <br /> <br />location: SC %, Nl~ %a, Section. <br />Township I S NQ Range (.4 E/®, ~}t,. PM <br />County "re lief <br />Subdivision ~~L) <br />Lot tit A , Blk n1 L1 , Flg nJlf~ <br />Hole(s) to be Constructed: Number <br />Estimated Oep[hz 10o F[. Aquifer_ <br />Purpose of Monitoring Hole(s) 1'Y1ar<•'Fn~ C..,..^d <br />Approximate Date of Construction lolzoo9 <br />~n.~ I ~iL <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- <br />Dlv. <br />PROCESSED BY <br />WD BAS _ MD DATE ACKNOWLEDGED <br />GROUND ELEV <br />USGS MAP <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE ORIWNG SITE. <br />Notice was provided co the State Engineer at leas[ 3 days prior co construction of monitoring & observaticn hole(s). <br />Construction of the hale(s) must be completed within 90 days of the date notice was given to [he State Engineer. <br />Testing and/or pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the Stale Engineer. <br />Water diverted during testing shall no[ be used for beneficial purposes. The owner of the hole(s) [s responsible for obtaining permit(s) <br />and complying with all rules and reguladons pertaining to [he discharge of fluids protlucetl during testing. <br />All work must comply with the Water Weli Construction Rules, Z CCR 402-2. Minimum consLrucdon standards must be me[ or <br />a valance obtained. <br />Well Construction and Test Reports (GWS-3l) must be 5ubmittetl to [his office by rite licensed contractor or authorized indlvitlual <br />within 60 days of the compledon of the work. <br />Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (7) year after constrvction. An Abandonment <br />Report (form GWS-9) must be submitted within 60 days of plugging & sealing. <br />The owner of the hole(s) should maintain records of water quality testing and submit this data to Ne State Engineer upon request. <br />The monitoring hole number, owner's structure name, and hole owner's name arW address must be provided on all well permit <br />appliradon(s). well conswcdon and abandonment reports. <br />A monitoring hole cannot be converted to a production water well. except for purposes of remediadon (recovery) or as a permanent <br />dewatedng rystem, it cortsvucted in accordance with the Water Well Conswcdan Rubs and policies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S~ CAN-9E-APPROVEII. <br />Additional Conditions <br />