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D6it 05-01 08:32 From:CC&V GOLD INVG. 17186803254 <br />cws.s[ NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />dgrot Please type or print ~C91DIy In DIaCk InK <br />Wetl Owner's Name ~ E V lfioFl INiniwc ~iae~goa;• <br />Landowner's Name Ltirf ~/ /~~! /Y1rn;__~M,ariny <br />Melling Agdress: (putnorizeq Inglvldual/or DAller) <br />ContaC[ -Tr'y/y FpM'1~./ ~,Eat/t[annLnJ'c.I l~tr,afiw, ,rA <br />Company Ck! iV rya/~~L(Y L1ffn~Qt <br />Atldress,.~b8ox f3/ <br />City. State. Zip V L~'a/ /e 4 fsorba <br />phone 7/4/ro139- YosS Fax No 7/g~( P- as <br />Driller Lic. No. (If applicable) A1C. r!/ia. ,~,Q~j,.rn`r Mf <br />Sato Monitoe Hola la mow' S <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH <br />Dlv <br />GROUND ELEV ___ USGS MAP fr <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Nd[ICe was prdvltled [d LfIC 5[e[0 Englneof e[ Ida$t d nays prior to CanSINC[Idn of 111oN[Ufing 6 DhedfVDLitlrl nce(sl <br />Construction Ur the hole(sl must be comple[Ctl within 90 days of the date ndlice Wai givdrl w the Stale Engineer. <br />Testing antllor pumping snarl riot exceed a total of 200 hours unless prior written approval ~s obtained tram the Slato Ertgineor. <br />Water diverted during tasting shall hat hd usotl for DeneflCial purposes. The ownor of the Hale(s) is resptlnsiDlo (ar obtaining pcrmit(sl <br />and complying with all rules arts regulations pertaining [o the discharge of fluids produced during tasting. <br />All work must comply with ehe Water Well Construction Rules, 2 CCR 402.2. Minimum construction standards must he mat or <br />o vaflenCd aD[ained. <br />Weil ConslrucGon antl Test Reports (GWS•311 must Da submitted to this office by the licansatl conuactnr or a~mon.od mAlvmual <br />within 60 days of [he completion of the work. <br />Unless a well permit is oDtainad, [he Hole(s) muss be pluggetl end sealed within one (1) year after construction. An Ahentlonrndnt <br />Report (form GWS-9) must ba submitted within 60 days of plugging & sealing, <br />Thv ownor of tna hole(s) cnvtaltl maintain roeords of water quality testing and submit this date [o ehe State Engineer upon request. <br />The monitDring hale number, owner's structure name. end note owner's name and address must he provided on all well permit <br />appl~cauon(s), well construction and abandonment reports. <br />A monitoring hole cannot be converted to D protluctian water well. oxcept for purposes ul remedintion (recovoryl or Ds tt pdrrnannnt <br />deWelCling Fy Slem, if GdnetruCletl In aCCdftlgntle with Lne Waldr WBII CDnSIfuC[idd Rull•Y and p011[Ie5 of Lhe $talr, F.ngulnlll <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />T-336 P.04/04 Job-065 <br />Location: SE V.. _~%., Sectlon~, <br />Township )S NQ Range ~_ E~ y~' PM <br />County T 1 /er - <br />su~divi""s~~io~~~~n h//A <br />Ldl ~rL , Blk _~~ . FIp..1J/rQ <br />HoID(s) [o be Cdnstructetl: Number ,- ~ . <br />Estimatetl Depth'y~ Ft. Aquifer _. <br />Purpose of Monitoring Hole(s) __.. ___ <br />4regrel f4~~t/ Maar{arin[. <br />Approximate Data of Constructibn,__,/2_L_p (, <br />PROCESSED 8Y <br />WD BAS __ MO ~ DATE ACKNOWLEDGED <br />Additional Conditions <br />