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DE`-06-01 08:32 Fram:CCiV GOLD lWG. <br />17186683264 T-336 P.03/04 Job-865 <br />cws.s, NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oarot Please type or print legibly In black ink <br />Well Owner's Name (~1 t/ Erb/d /nr11r~E ~o.rrporitrr <br />Landowner s Name G"Lr'V Geld mrwrtra /A ,.y <br />Melling Address: (AAuthorized IndlvldueVor Driller) <br />Contact rtuat~ LOrNt~ J Q)uar ~! /' d d•~a. It1- <br />Company ~= t/ 6DL'J tNtaf.a._ r~~ <br />Address 'Ao Sae t~l <br />City, State, Zip U~,~n[~ Colenic!- tt0~60 <br />Phono ' ~(eB2- MOSS fax No. ?f~a.cw~ <br />Driller Llc, No. (Ir applicable) ~k ~l/L~ Xaa~g,)r HST <br />Slta Monitor Bola 1~ ~.P42JN-i <br />Location: SE Y.. ~S _Yi, Seccion~~_. <br />Township ~s N61 Range -~ ELSA~ 4~ PM <br />County TE//e/ <br />Subdivision N/A , <br />Lot _~~ , Blk N II' , fig U~1~ <br />Hole(s) to be Constructed: Number <br />Estimated Depth 4-~~ F[. Aquifer <br />Purpose of Monitoring Hole(s) <br />~-. <br />Approximate Datc of Construc[lon <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- <br />Dlv. _ WD BAs _ MD <br />PROCESSED BV <br />DATE ACKNOWLEDGED <br />GGOIJND ELEV <br />USGS MAr 8 <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OP THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Notice was provided u, the State Engineer a[ lobsl 3 days prior to construction o! monitoring & ohseruatian hale(s). <br />Construction of the bolo(s) must be completed within 90 tlays of the date nonce was given to the State Engrneer. <br />Testing andfor pumping shelf not exceed a total of 200 hours unless prior written approval is obtained From the Sato Engineer, <br />Water diverted during resting shall not be uSOd for beneficlol purposes. The ownor of the hole(s) IS responsible far obtaining pormlt(s) <br />and Complying With all rules and ragt+latlonc pertaining to the discharge o/ fl~itla producatl during [os[Ing, <br />All work must comply with [ha Water Well Construction Rules. 2 CCR 402.2. Minlntum construction standards must be met or <br />a varianeo obtained. <br />Well Construc[lon and Test Reports (GWS-31) must be submitted to this office oy the licensed contractor nr autnorited individual <br />within 80 dogs of the complatldn of [na worK. <br />Unless a well permit is dbtainbo, the hole(s) must be plugged and soared within one (1) year after construction. An Abandonment <br />Roport (form GWS•gl must be submitted within fi0 days of plugging ar sealing. <br />The owner of the hole(s) shoultl maintain records of water quality testing and submit [his date td the State Engineer upon request. <br />Tme monitoring hole number, owner's structure Homo, and hole owner's Hama and address must be provided on all well permit <br />appllcalion(sl, woll construction and abandonment reports. <br />A monitoring hole cannot Oe converted to a production water woll, oscept for purposes of remadla[ion (recovery) or as a permanent <br />dewatoring system, 11 constructed in accordance witn the Water WeII Construction Rules and porlelas of the sta to 6nginoar <br />THIS ACKNOWLEDGEMENT OFNOTICE DDES NOT INDICATE THAT WELL PERMR(5) CAN BE APPROVED. <br />Additional Canditlons <br />