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<br />cws.st NOT(CE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oyos <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 303.866589 <br />AUTHORIZED INDMDUAL OR DRILLER sr{~ Fn : Cerz- L ~rf <br />Contact ~o~ K+~1 ~ <br />Company A K Dn. l~r.,~te7c <br />Addre55 I YS C p0.rlt'MUn} <br />City, Slate, Zip 73/{txs~W!< $4~0( <br />Phone'For.-:kz- 8S"A6 Fax No. 4oa-}Ffz-_ Z~53 - <br />Driller Uc. No, ('rf applicable) v~ <br />Well Owner (CtieMqA) irrfonnation n <br />Name ~•~< VuL,E ~ i/i~ow ~~~ ~~•rrn; ( o <br />Address Sox l51 <br />Well Owners Phone ~F15 - r.Y4 - 5`uS G <br />Landowners Name: C,r-,r~vk Cauk i V,~-lo++-~ ~olcl 4vi,~,„g (y <br />--•r <br />MH- <br />Location: Ne %, 5 ~ '/., Section ! ~" <br />Township L N ~ Range by E /~ PM 6 ~~ <br />County itltc <br />Subdivision N/A _ _ _ <br />Lot N A 81k. N A Flg. N~ <br />SitelPropertyAddress ~~N>t. ~o kL <br />Hole(s) to be constructed: Number -&~- '1- <br />Estimated depth ~o O Ft. Aquifier <br />Purpose of Mandoring Hale(s)1w~wr'E~r. Ks <br />ConsIW~~dion <br />¢35r 3 wirha <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />PROCESSED BY <br />DN. WD BAS MD <br />DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRnTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIWNG SITE. <br />Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). Construction <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 total of 200 hours unless prior wdtten approval is obtained from the State Engineer. Water diverted during testing shall not be <br />used for benefidal purposes. The owner of the hole(s) is responsible hr 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 with the Wa6er Weti ConsLuction Rules, 2 CCR 402-2. Minimum construction standards must be met or a <br />variance obtained. Standard permit application and work report forms are found on the DWR Hebsde at hthr./lwww.water.state.co.us. <br />Well Construction and Test Reports (GWSJ1) must be completed for each hole drilled. The licensed contractor or authorized individual <br />must wbmit the completed fortes to this office within 60 days of drilling. <br />Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after consbuction. <br />An Abandonmerrt Repoli (form GWS-9) must be submit6ed for each hok: plugged within 60 days of plugging & seating. The <br />rtronitorirrg Prole adcnawiedgement number, owner's structure name, and hole owners name artd address muss be provided on aq weN <br />permit application(s), well mnsWdion and abandonment 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 cannot be converted to a production water Hell, except for purposes of remediaticn (recovery) or as a permanent <br />dewatedng system, rf constructed in accordance with the Water Well Construction Rules and polities of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE GOES NOT INDICATE THAT WELL PERMR(S) CAN BE APPROVED. <br />IF HOLES WILL MOT 8E CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE''+YRtTE, "MO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WRH THE FILE NUMBER AND FAX THE COPY TO THE DMSION OF WATER RESOURCES. <br />Additional Carrditions <br />