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cws-st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) -- <br />o1ro1 Please type or print legibly in black ink - <br />Well Owner's Name ~dinnlr. CrccK E ~cbr Cnolc! fV)In,ng C,nw.aa4` Location: Sr V~. ~.%<, Section (~ , <br />Landowner's Name r~lpolc Crr~K r VK~Ir 4old YNiw\~r,~, In+npan,~ Township IS_ N(S~ Range Oq E~ (off" PM <br />County Te Uer <br />Mailing Address: (Authorized IrWividual/dr Driller) <br />Contact Tirylm Com¢~ /Chi<~ cSvwrn nn<..do./ Cua rd~M.~e/ <br />Company Cn (s Grr.~. f I/i~6,r C~okl nA. h [1,,..,na,..i <br />Address QU UUY 191 <br />City, Slate, Zip _ Ulc•nrr Cd 8yS60 <br />Phone 719~LoSS54oS5 Fax No. 719~(r>g9325~{ <br />Driller Lic. No. (if applicable) <br />sa+c = 0 : ~-1 l~ hA W - I b ~ <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- <br />Dro. WD BAs _ MD _ <br />PROCESSED BY <br />DATE ACKNOWLEDGED <br />GROUND ELEV <br />USGS MAP ~ <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACXNOWLEDGEMEM SHALL BE AVAILABLE AT THE ORIWNG SITE. <br />Notice was provided to the Stale Engineer a[ least 3 days prior to conswcdon of monitoring & observation hole(s). <br />Construction of the hale(s) must be completed within 90 days of [he date notice was given to the Slate Engineer. <br />Testing and/pr pumping shall not exceed a [oral of 200 hours unless poor written approval is obtained fmm the State Engineer. <br />Water tliverted during testing shall not be used far beneficial purposes. The owner of the hole(s) is responsible for obtairing permit(s) <br />and complying with all rules and regulations pertaining to the discharge of fluids produced during testing. <br />All work must comply with the Water Well Construction Rules. 2 CCR 402-2. Minimum construction srandards must be me[ or <br />a variance obtained. <br />Well Cons[nuction and Test Reports (GWS-37J must he wbmittetl [o this office by [he Itcensed convattor or authorized individual <br />within 60 days of [he completion of the work. <br />Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (7) year after constuction. An Abandonment <br />Report (farm GWS•9) must be wbmitted within 60 days of plugging & sealing. <br />The owrrer of the hale(s) shpufd maintain records of water quality teszing and wbmit tltis data to [ha State Engineer upon request. <br />The monitoring hole number, owner's structure name, and hole owner's name and address must be provided pn all well permit <br />application(s), well coretrvction 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 />tlewatering rystern, i( conswaed in accordance with Ne Water Well Construction Rules and policies of the Srate Engineer. <br />THIS ACl(NOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT( CAN BE APPROVm. <br />Subdivision ulr+ <br />Lot N) A , Blk IU R , Flg AJ~/-L <br />Hole(s) [o be Constructed: Number <br />Estimated Oepthx8oo Ft. Aquifer_ <br />Purpose of Monitoring Hole(s) YY1on,'Eor C~.,,._d <br />Approximate Date of COnsvlldClbn I °'wo~( <br />l GvWn~ ~rn.--~ <br />Additional Cond(dans <br />