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l- <br />cwss~ NOTICE OF INTENT 70 CONSTRUCT MONITORING HOLE(S) <br />03105 <br />Please type or print legibly in black or blue ink <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203 <br />Phone 303-866-3581 Fax 303-8663589 <br />AUTHORIZED INDIVIDUAL OR DRILLER S~ rc ~° ~ lr R - G ? S- <br />Contact T~v K~ <br />Company ~6K Lai/G.,i FN/. <br />Address 1X5 SwtL ~uz~»f <br />City, State, Zip ,3~#c~ ~t S$~0/ <br />Phone 4oC- ~FSL- y5"p6 Fax No. 4ro6 - ~'6L- Z3~f3 <br />Driller Lic. No. ("d applicable) N A <br />Wel! Owner (Client) Information <br />Name Gi' yo/r /'weGE s i~~oL ~rn~r~ ~~,.~~~ <br />Address ~°~ ~/ I <br />Well Owners Phone ~/ 5- ~~= rf° S" ~ <br />Landowners Name:P~,/c ~'aE c Ue~a~ GvIG( U/-~o~ <br />Hole(s) to be constmded: Number <br />Estimated depth /~Gb Ft. Aquifer <br />Purpose of Monitoring Hole(s) ftmhrr{~.r..,~ <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- PROCESSED By <br />Dlv. _ VJD BAS_ MD <br />DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRfiTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Notice was provided to tfie State Engineer at least 3 days prior to construction of monitoring 8 observation hole(s). Construction <br />of the hale(s) must be completed within 90 davs of the date notice was given to the State Engineer. Testing andlor pumping shall not <br />exceed a total of 200 hours unless prior written approval is obtained from the Stale Engineer. Water diverted during testing shall not be <br />used for benefidal purposes. The ovmer of the holes) is 2sponsible for obtaining permit(s) and complying with alt rules and regulations <br />pertaining to the tlischan3e of fluids produced during testing. <br />All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum construction standards must be met or a <br />variance obtainetl. Standard pertnR application and work report fortes are found on the DWR websde at htln:/lwww.water.state.co.us. <br />Well Consbvction and Test Reports (GWSJ1) must be completed for each hole drilled. The licensed contractor or authorized individual <br />must submd the completed farms to this office within 60 days of drilling. <br />Unless a well permit is obtained, the hoe(s) must be plugged and sealed within one (1) year after construction. <br />An Abandonment Report (forth GWS-9) must be submitted for each hole plugged within 60 days of plugging 8 sealing. The <br />monitoring hole acknowledgement number, ow~neYS slrudure name, and hole ownefs name and address must be provided on all well <br />permit appliption(s), well construction and abarxionmeM reports. <br />The owner of the hole(s) should maintain records of vrater quality testing and submit this data to the State Engineer upon request <br />A mon8oring bolo cannot be converted to a production water well, except for purposes of remediation (2cavery) or as a permanent <br />dewatering system, if consWded in accortlance with the Water Well Construction Rules antl polities of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WRHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WfTH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />Location: NuJ Y,, S~ Y., Section r ?- <br />Township / S N .~ Range ~ E ~ P <br />County ~[/b2 <br />Subdivision ~//A _ _. <br />Lot N A , Blk. N A Flg. N ft <br />Site/Property Address ~~nh. Qo ~L <br />Addirmnal Conditions <br />