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cwss, NOTICE OF INTEN7 TO CONSTRUCT MONITORING HOLE(S) <br />03105 <br />Please type or print legibly in blade or blue rnk <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203 <br />Phone 303-866-3581 Fax 30366-3589 <br />AUTHORIZED INDIVIDUAL OR DRILLER s,+r LD : Ga - 63G <br />Contact 7,r~ ~~ <br />Company ,4K J2i ~rivL .ZnC <br />Address / ks' S~~z<~ `/~c t~r~,o.~~ <br />City, State, Zip 3u#C~ ~t SS~OI <br />Phonef`l/ --~7 - XSO C Fax No. ~l06 - ~kZ- Z~~i,3 <br />Driller Lic. No. (if appligblej NSA <br />Well Owner (Client) Information <br />Name ~e~pilc (.t'ec~ ~ rc~oc ld<~~ ~",s <br />Address / ~+~ /Sl <br />~cfo.e. , C% / F~ Y~ o <br />Well Ownefs Phone 215' 6~5 -~/oSG /// <br />Landowners Name: 2x ~~c ~<e~ S V~r~t ~olr~lZli+~/ ~s L~ <br />Lot ni/~ . Blk. ~/ ~ Flg.~ <br />Site/PropertyAddress C~"n/% ,QD 8L <br />Hole(s) to be constructed: Number / <br />Estimated depth 00 Ft. Aquifer <br />Purpose of Monitoring Hole(s) aux.~oni.a~ <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- PROCESSED BY <br />Dlv. _ VVD BAS MD <br />DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Notice was provided to the State Engineer at least 3 days prior to construction of monitoring 8 observation hole(s). Constmdion <br />of the hole(s) must be completed within 90 davs of the date notice was given to the State Engineer. Testing and/or pumping Shall not <br />exceed a iota! of 200 hours unless prior written approval is obtained from the State Engrneer. Water diverted during ies5rtg shall not be <br />used for benefidal purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying with all rules and regulations <br />pertaining to the discharge of fluids produced during testing. <br />All work must comply witlt the Water Well Construction Rules, 2 CCR 402-2. Minimum consUUdion standards must be met or a <br />variance obtained. Standard permit application and work repot forms are found on the DWR websde a! hfto:/lwww.water.stale.co,us. <br />WeII Construction and Test Reports (GWSJ1) must be completed for each hale drilled. The licensed contractor or authored individual <br />must submit the completed forms to this office within 60 days of drilling. <br />Unless a well permit is obtained, the hole(s) must be plugged and sealed wRhin one (1) year after construction. <br />An Abandonmerrt Report (form GWS-9) must be submitted for each hole plugged within 60 days of plugging & sealing. The <br />monitoring hole adv,owtedgemem number, owners sWdure name, and hole owner's name and address must be provided on all well <br />pennd appliptian(s), well censWCtion and abandonmem reports. <br />The owner of the hole(s) should maintain records of water quality testing and submd this data to the State Engineer upon request. <br />A monitoring hole pnnot be converted to a produc5on wafer well, except for purposes of 2mediation (recovery) or as a permanent <br />dewatering system, if constructed in axordance with the Water Well Construction Rules and polities of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />(F HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 GAYS, PLEASE WRRE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />Location: ~ %, N1= Y., Section / ~ , <br />Township ~ N ~ange 1z:L_. E l /J PM~/o -~ <br />County tel(~n--- <br />Subdivision N <br />Additional Candrllons <br />