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~ws-sr NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />o3lm Please type or print legibly in black ink <br />Well Owner's Name ClfjRpJr. Cr[raC £ yl~6f (7~old min,ar, Cu.nd44.~ <br />Landowner's Name Crilpplc (jfrclC 7 VI<b. do (d I'`Airir`4 In.n pansy <br />Mailing Address: (Authorized Individual(or Driller) <br />Contact ~rYnm(^orwr ~CN]ic~Liavr on.ncn~/C'w rd~~+..~~ <br />Company Cnooln CircL~. q Ur~f~. C nkl M !i+ a..~ <br />Address pU Bou 191 <br />City. State, Zip Ulc•+~'r CCU 8C~8~0 <br />Phone 719~cog94C6$ Fax NO. 719~(rkS9325'-{ <br />Duller Lic. No. (if applicable) <br />S[+~ S 0: C~ Ulan w- I ~ A <br />Location: SU/ %. ~1~%<. Section 17 <br />Township I S NAB Range Cog E~ IoH"' PM <br />County Te Ilef <br />Subdivision ~~~ <br />Lot nJ A Blk ~ A , Flg ~[J~/-L <br />Hole(sj to be Consvucted: Number ) <br />Estimated Depth"~i~ F[. Aquifer <br />Purpose of Monitoring Hale(s) fV1on~~o. C..,.._d <br />LtJo.~rt L~~~Is __ <br />Approximate Date of Construction I o /200( <br />(~('r11~ <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 ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIWNG SITE. <br />Notice was provided co [he State Engineer ac leas[ 3 days prior [o construction of monitorng & observation hole{s). <br />Consiruction of the hole(s) must be comple[etl widhin 90 days of [he dace notice was given [o [he State Engineer. <br />Testing antl/or pumping shall no[ exceed a total of 200 hours unless poor written approval is obtained from [he State Engineer. <br />Water divertetl tludng testing shall not be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining permit(s) <br />and complying with all rules and regulations pertaining to [he discharge of fluids produced during testing. <br />All work must comply with [he Water Well Consbucdon Rules. 2 CCR 402-2. Minimum construction standards must he met or <br />a vadance obtained. <br />Well Construction and Test Reports (GWS-3l) must be wbmitted co mis ofFce by u[e licensed contractor or autnonzee individual <br />within 60 days of the completion o! the work. <br />Unless a well permit is obtained, [he hale(s) must be piuggetl and sealed within one (l) year after construction. An Ahantlonmenc <br />Report (farm GWS-9) must be wbmitted within 60 days of plugging & sealing. <br />The owner of [he hole(s) Should maintain retards of water quality testing and submit this data co [he Slate Engineer upon request. <br />The monitoring hole number, owner's structure name, antl hole owner's name and address must be provided on all well permit <br />application(s). well coretrucrion and abandonment reports. <br />A monitoring hole cannot be converted m a production water well. except for purposes of remetlWtian (recovery) or as a permanent <br />dewacedrrg system, if constructed in accordance with Ne Water Welt Construction Rules and pdicies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPRO7E$- <br />Atltli[ibnal Contlitions <br />