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cws.st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />o~os <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 303-8863589 <br />AUTHORIZED INDMDUAL OR DRILLER <br />r y <br />Contact /l~vtM time/~~7KF~fflul.Ewnr„/.~/ /COVd~~/c// <br />Company CC £ V bid /I'),n,nti /v~ n.. <br />Address_ ~ PoX 1°il <br />City, State, Zip l~lcfor lDlo,T,L(rJ ~SOg(p0 <br />Phone__TI9~Co~ i -Zy77 FazNo. ~i4/ro$q- 3Z5~/ <br />Driller Lic. No. (if aoolipblel <br />Well Owner (Cliertt)Infotmatlon S,+cTp :~~sH~3 <br />~t TsS, <br />Name eC f i/ (ZO k1 mrn,ng lo.n/Xn~ <br />Address ~U ~3oX Iq 1 <br />UILFe(+ CU ~C~g(~ <br />Well Owner's Phone `714 ~ G & ~ -a 4~7n7 ~7~~ <br />Landowners Name: eC'V C7~Ic.l /rd~lraz CLni/Kn(/ <br />r <br />Hole(s) to be constructed: Number, <br />Estimated depth x 5~ FL Aqufier <br />Purpose of Monitoring Hole(s) <br />L(/alc/ Le/cl 117on~lvrm <br />Approximate Date of Construction ~<u ~c JLLIy X zao~ <br />(Must et least 3/d/~a~"ys prior to mnshucUOn) <br />J/J/LJAA~r L~> <br />Authorized Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- PROCESSED BY <br />Dlv. _ WD BAS_ MD <br />DATE AclwowLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Notlrx was provided fo the State Engineer at least 3 days prior to consVUCtlon of monitoring & observation hole(s). ConsWdion <br />of the hole(s) must be completed within 90 days of the date nofiice was given to the State Engineer. Tesfing arW/or pumping shall not <br />exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing shat not he <br />used for henefit9al purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying with all rules and regulations <br />pertaining to the disrharge of fluids produced during testing. <br />All work must comply with the Water Well Constructlon Rules, 2 CCR 402-2. Minimum construction standards must be met or a <br />variance obtained. Standard permit application and work report fomu are found on the DWR website at htto:/hvww.water.state.co.us. <br />Well Consfructlon and Test Reporffi (GWSJ1) must be completed for each hole drgled. The licensed contractor or authoraed individual <br />must submit the completed forms to this office within 60 days of drilling. <br />Unless a well pemrk fs obtained, the hole(s) must be plugged and sealed within one (1) year after constrouion. <br />An Abandonment Report (form GWS~) must be submhted for each hole plugged within 60 days of plugging 8 sealing. The <br />monitoring hole acknowledgemenlmsmber, owners strutxure name, and hole owner's name and address must be provided on ail well <br />permd application(s), well construction and abandonment reports. <br />The owner of the hole(s) should maintain records of water quality testing and submit this data to the State Engineer upon request <br />A monitoring hole cannot be converted to a production water well, except for purposes of remediation (recovery) or as a permanent <br />dewatering system, if tbnsWcted in accordance with the Water Well ConsWdion Rules and polities of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMR(S) CAN BE APPROVED. <br />IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WRHIN 90 DAYS, PLEASE WRfTE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGEb NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DMSION OF WATER RESOURCES. <br />Location: 5~%., St '/., Section (~ <br />Township ~5 N lm Range (c4 E ~, PM ~~' <br />County Te!/ri <br />Subdivision ,U/r4 <br />Lot N/~ BIk. n//i¢ Flg. ~t//Kl <br />Site/PropertyAddress Tllc~ ~ ~ ~aocf ~3 <br />Additional Conditions <br />