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uaiu-r,euud lz:un rte rla nso urAs <br />.jtAen vt'tt AAUS t Any <br />I~..V VJ/ VVJ <br />cws=_' _ . NOTICE OF INTENT TO CONSTRUCT IAONITORING HOLE(Sj <br />Please type or poor legioy in black cr blue ink <br />Colorado Division of Water Resourctas 1313 Sherman St-Room 821 Denver CO 80203 <br />Phone 303-b66-3587 Fax 303-$66-358!1 <br />AUTHORIZED INDINDUAL OR DRILLER <br />Contact Jack Allen <br />Company 911en brillipy,?n~ <br />Address Post Office Rox 398 <br />City, State, Zip Fairvlay, Colorado 80440 <br />Phone (719) 836-26;2 FazNo. 719) 836-0715 <br />Driller Lic. No. (it appicada) 7fi3 <br />W.II Owner (Client) Inlbrmatlon <br />Name Jack Allen <br />Address Pcst Office Rox 356 <br />Fairolav. Colorado 90440 <br />Well Owttefs Phone (7191 836-2672 <br />Lancawner's Name: Jack A11en <br />M H- <br />Dlv. WD BAS MD <br />DATE ACIQJOWLEDGED <br />OFFICE <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNO'NLEDGEMENTSHALL BEAVAILABLE AT THE DRILLING SITE <br />Notlce was provided to the State Engineer at lee st 3 days prbr to construetlon o} rttonltodng & observatlon hde(s). ConsWCtcn <br />of the holes? must be completed within 90R~ of the date voice eras given to the State Enginer.. Testing antler pumping shah not <br />exceed a rota) of 200 hens uNess prior wdtten approval is obtained from the State Engineer. Watsr aveCed during vesting shall not be <br />useC for benefida; purposes. The owner of the hole(s) is responsible for obtaeting permit(s) and complying with all rules and regulatlons <br />pertaining to the discharge of fluids produced dunnt< testing. ' <br />All work must comply wdh the Water Well Cons,:ruction Rules, 2 CCR 402.2. Minimum consavetion standards must be met or a <br />vzriance obtained. S[acdard permit application and wore: report-forms are bond cn fie DNR wedsite a! httodAvww.waterstate.co.us. <br />Welt Construction and Test Reports (G WS-~Q must be completed for each hole crated. The licensed contraccr cr authorized individual <br />must submit the ccnple:ed Corns to this cftice wtnir 60 days or tlnlling. <br />Unless a well permit is cbtalned, the hole(s) tnuf:t be plugged and sealed within one (1) year aRer construotlon. <br />An Abandonment Report (corm GWS-9) must be submitted for each hae plugged v,ri thin 60 days of pluggktg 8 sealing. Tine <br />moni:cnng hole acknowledgement number, owner's seucerre name, aad hole owners name and ao dress must be provided on elf well <br />perrrut applicaten(s), Hell consructon and abantlcn rent repors. <br />The owner of the tic!e(sl should maintain records of rvater qualiy testing and submit Cos date to the State Engineer upon request. <br />A monitoring hole cannot oe converted ro a production water well, ezcep[ for purposes of; emediadon (reccvery) or as a permanent <br />de~rraterng system, it constructed in atx;ordance Wirt the Water WeII Ccre7uction Rules and poFCies of :Fie State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES f10T INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />+F HOLES WELL NOT BE CONSTRUCTED UNDER TIiIS NOTICE WITHIN 90 DAYS, PLEASE 4J,417E, "NO HOLES CONSTRUCTED" ON A <br />Cv^PV OF THE ACKNOWLEDGED NOTICE N11TH THE FILE NUMBER AND FAX THE COPY TO7HE DIVISION OF WATER RESOURCES. <br />Loeatlon: ~_%, _~_'/., Becton 14 <br />Tuwrship~~A/S,Range~Z$IW,PM 6th <br />Gaunty nark _ <br />Sub?~vision <br />Lo; Blk. F!g. <br />SitelFropeRy Address Section ]1 S i4. ;owns 'p <br />10 Soutit, Range 77 West <br />11o1e(s)to be constvctetl: Nvmber 2-Sec 14 .g 1 • Sec 11 <br />Estme[ed deptt ~Q,_Ft Aquifer Q1 a r t a t p i T t y 1 <br />Purpose of Monitoring Hole(s) Division of Mirer s <br />and Geolo>;y <br />Appronmate Date of Constrrcdon Aoril 12, 1.2006 <br />(Mwt De et least 3 aen q-pr b carewcuont <br />ACKNOWLEDGEMENT FROM STATE HVGIN' <br />FOR OFFICE USE ONLY <br />PRO~::ESSED BY <br />Addi;ionai Condtions <br />