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cws-sl .NOTICE OF IMENT TO CONSTRUCT MONITORING HOLE(S) <br />ovot Please type or print legibly in black ink <br />well Owner's Name ~j~plr- C+tr.K Y ~ob+ /~ulcl YVIIn,nS Cuw.daM) Location: SW /,, NC +/<, Section I ~ , <br />Landowner's Name rr,/JOIc t~rr~IC r Vl~b. Etu(d V^>`ihj,.a In.npan.~ Township IS N(~ Range _p(~ E nom. (.*' PM <br />County "refer <br />Mailing Address: (Authorized Individual/or Driller) <br />ContactTmmCon.¢~ rCh~ FEi~lwonm -fa./ Co .-d»..~~ <br />Company Crr [e CsrcL 4 (/IC{u+ C~okl !t<, Cln_~n~/ <br />Address QO ~iX 141 <br />City, State, Zip ~Lc }orr CCU gCu gel) <br />Phone 719~(oFf94oS5 Fax No. 719~(nS4325'-{ <br />Subdivision _.~~~ <br />lot ~ R , Btk n1 A , Ftg ,tJ/l~ <br />Hole(s) to be Constructed: Number <br />Estimated Depth ^ Soo Ft. Aquifer <br />Purpose of Monitoring Hole(s) YY1on, ~o~ ~ ~.>r^d <br />Ltb.~ L<v.-Is <br />Approximate Date of Construction 1 O ~7~u~'( <br />Driller Lic. No. (if applicable) A) ~!~ <br />st+~ ro : G ul~~ -I-(t3 <br /> <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- <br />Drv. <br />WD BAs MD <br />-PROCESSED BY <br />DATE ACKNOWLEDGED <br />GROUND ELEV USGS MAP it <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 [o the Slate Engineer a[ leas[ 3 days prior to constrUCdon of monitoring & ob5ervadan hole(s). <br />Construction of the hole(s) must be completed within 90 days of the date notice was given to the State Engineer. <br />Testing and/ar pumping shall no[ exceed a total of 200 hours unless pdor written approval is obtained from the State Engineer. <br />Water diverted during testing shall not ce used for beneficial purposes. The owner oP We hole(s) is responsible far obtairnng 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 Coretmcticn Rules. 2 CCR 402-2. Minimum construction standards must be met or <br />a variance obtained. <br />Well Construction antl Test Reports (GWS-31) must be wbmittetl to [his office by [he licensed contrattor or authorized individual <br />within 60 days of [he completion of the woM. <br />Unless a well permit i5 obtained. [he hale(s) must be plugged and Sealed within one (l j year after constntction. An Abandonment <br />Report (form GWS-9) must be submittetl within 60 days of plugging & sealing. <br />The owner of the hole{sj should maintain records of water quality testing and submit this data to the State Engineer upon request. <br />The monitodng hole number. owner's strttcture name, and tale owner's name and address muss be provided on all well permit <br />application(s), well coretrvction and abandonment reports. <br />A monitodng hole cannot be converted to a production water well, except far purposes d rrmetliadon (recovery) a as a permanent <br />dewatedng system, if constnxted in acrnrt7ance with [he Water Well Conswcdan Rules and policies of the State Engineer. <br />THIS ACXNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVEil. <br />Additional Conditions <br />