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GWSS, NOTICE OF INTENT TO GONSTRUCT MONITORING HOLE(S) <br />03/05 <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 303-8663581 Fax 303-866.'i589 <br />AUTHORIZED INDMDUAL OR DRILLER <br />Company CGsU Gold {'YlrnrnG r`int/gnu <br />Address ~a fix 14l <br />city, state, zip Ilrc(n~ Co ko13(no <br />t <br />Phone 71 t/!~4 ' <~Y~7 Fax No. 7/4 f (P S^i - 325"`7 <br />Well Owner <br />5,~ rd •. p5g6f1-2 <br />Name G'C s V Czv/c/ /jq„~1h5 ~ nu <br />Address _. ~G Sul! 14/ <br />Well Ovmer's Phone <br />Landowner's Name <br />MH- <br />Dlv. _ 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 tD the State Engineer at least 3 days prior t0 constnrcUon of monitoring $ observation hole(s). ConsWdio„ <br />of the hole(s) must be completed within 90 davs of the date notice vrds given to the Slate Engineer. Testlng andlor pumping shall not <br />exceed a total d 200 hours unless prior written approval a obtained from the State Engineer. Water diverted during testing shall not be <br />used for berleficlal purposes. The owner of the hole(s) is responsible far obtaining permit(s) and cemptying with all rules and regulations <br />pertaining to the discharge of fluids produced during testing. <br />All work must comply with llte Water Well l:onslruction Rules, 2 CCR 402-2. Minimum consWction standards must be met or a <br />variance obtained. Standard permit application and work report forms a2 found on the DWR website at httoJhvww.water.sfate.eo.us. <br />Well Construction and Test Reports (GWS-31) must be completed for earn hole drilled. The licensed contractor or authorized irW'Nidual <br />must submit the completed forms to this office within 60 days of drilling. <br />Unless a well pemrk b obtained, the hole(s) must be plugged and sealed within one (1) year after constnrctlon. <br />An Abandonment Report (form GWS~) must be submitted for each hole plugged within 60 days of plugging b sealing. The <br />monitoring hole advrowledgemeM number, owners sWdure name, and hole owners name and address must he provided on all welt <br />permit application(s), well consWction and abandonment reports. <br />The owner of the hole(s) should maintain records of water quality testing and sutxnit this data to the State Engineer upon request <br />A mon'ttorirg hole cennot be converted to a production water welt, except for purposes of romediafion (recovery) or as a permanent <br />dewatering system, ri consWcted in aaordance with the Water Well ConsWdion Rules and policies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDIGATE THAT WELL PERMR(S) CAN BE APPROVED. <br />IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRfTE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DMSION OF WATER RESOURCES. <br />Location: ,~1~X, SE '/., Section 11 <br />Township 1 S N~'7S Range t~ 9 E l~M PM lo'~ <br />County TII~/ <br />Subdivision N/A <br />Lot Nfq • BIk. N/A Fig. ~cJ/R <br />Site/ProperlyAddress T/~i ~~..~Fy ~~i 83 <br />Hole(s) to be constructed: Number <br />Estimated depth x So Ft Aquifer <br />Purpo,s,e/ of Monitoring Hole(s) _ <br />WAY( Le,,e~ /Y)on, ~vri~ <br />Approximate Date of ConsWCtion l~<r <F .I.. LF,,~-r 7 <br />(MUStyeal least 3 days piarEO construrlon) <br />//(//~/~~C ~~- <br />Autharized Signatrue <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />-. _ _ PROCESSED BY - <br />Additional Cond'dions <br />