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cws.st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oaos <br />Please type or print legibly in blade or blue ink <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203 <br />Phone 303-866-3581 Fax 30388-3589 <br />AUTHORIZED INDMDUAL OR DRILLER <br />Company <'[~_ c V L-told YVtin,~a Co ni/ <br />Address ~ Box IqI <br />City. State. Zip Ut~~~~ Colorcdo gUFftoo <br />Phone `719~65rr-agZ7 FazNo. 719)toR4-3Z5~ <br />Drill/e~r LlI.ic. No. (if appliceble) <br />_ ~(` ~rl l(lr\4 <br />WellOwner(Client)Informatlon Srlc Tp = OSr}gH-5 <br />Name CG ` f ~~otd M~ nrr~ Corn~i..y <br />Address ~ LoK 141 <br />V l~~or ~ CU ~OZ(o0 <br />Well Owners Phone ~I ~ ~ /O 89 - 2 ~r 77 <br />Landowners Name : CC ° (/ 6o Icf /Ylr~~ r , n i. <br />MH- <br />Dlv. WD BAS_ MD <br />DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRfTTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE ORIWNG SITE. <br />Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observa8on hole(s). ConsWcfion <br />of the hole(s) must be completed wthin ~ dove 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 written approval is obtained from the State Engineer. Water diverted during testing shalt not be <br />used for benefidal purposes. The owner of the hole(s) is responsible for obtaining pertnR(s) and complying with all rules and regulations <br />perhaining to the discharge of fluids produced during testing. <br />All work must comply with the Water Well Corretruction Rules, 2 CCR 402-2. Minimum censWction standarcls must be met or a <br />variance obtained. Standard permit appricafion and work report forams are found on the DWR websde at htto:/Mrww.waterstate.co.us. <br />Well Construction and Test Reports (GWS31) must be completed for each hole drilled. The licensed contractor or authored individual <br />must submit the completed forms to this office within 60 days of ddliirg. <br />Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. <br />An Abandonment Report (form GWS~) must be submitted for each hole plugged wMhin 60 days of plugging & sealing. The <br />monitorirg hole acknowledgement number, owners structure name, and hole owners name and add2ss must be provided on all well <br />permit application(s), well censWrtion 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 remediagon (recovery) or as a permanent <br />dewaterirg system, if constructed in accordance with the Water Well Construction Rules and polices 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 WITHIN 90 DAYS, PLEASE WRfTE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE flLE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />Location: Se '/., SE y,, Section 17 <br />Township I S N /~ Range ~9 E,~FI PM 6+~' <br />County /r/her <br />Subdivision ///A , <br />Lot N/~ . BIk. il//A . Flg. ~~~ <br />Site/Property Address T I l<r ~o4.d.~P<:,<~ B3 <br />Hole(s) to be censWcted: Number, <br />Estimated depth xSV Ft. Aquifer <br />Purpose of Monitoring Hole(s) <br />(~cc,!~r Lpv< /17rm,1a+r <br />Approximate Date of ConsWdion e<.k ~ J~/y~2ec7 <br />(Masi he ar least 3 Rays Priorb mnstruclim) <br />Authored Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />PROCESSED BY <br />Additional Conditions <br />