Laserfiche WebLink
cws.st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oa~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 303-8663589 <br />AUTHORIZED INDMDUAL OR DRILLER <br />Contact I II1~tt? ~GWte/ /C'l7{~{ <br />Company ~C` ` / ~ZOld f~rnih, <br />Address no 'Izx 191 <br />City, State.Lp Ulc.~ur ~~lovrrlU <br />Phone `7)cr~CaS"=r-x477 Fax No. <br />Driller lic. No. ('d aoolipblel <br />~ (OrN/Jan~ <br />$Ogrd y <br />71~i ~ io&ti - 3ZS'/- <br />Well Own/eyr (CIIeM) Information /~ S, (c Td : OSASA - 5 <br />Name 1.L~7.'1/ ~70/~ l'nt n,n lbm aN~ <br />Address /"~ ~on' /9/ <br />/ao No//~ 3"t s~~et <br />l~lC l0/~ (rD ~(i ~(od <br />Well Owner's Phone 719 ~ CgSti - a 9 ~ 7 <br />landowners Name : L'C f (/ (zo,F~! ~y/1Me (onn/~vtn v <br />MH- <br />Dlv. <br />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 ib the Stele Engineer at least 3 days prior to constmuNbn of monitoring 8 observation hole(s). ConsWdion <br />of the hole(s) must be completed wiUlin 90 davs 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 shall not be <br />used for beneficial purposes. The owner of Ore hole(s) is responsible for obtaining permit(s) and complying with all rules and regulations <br />pertaining to the discharge of fluids produced during testing. <br />All work must compty with the Water Well Construction Rules, 2 CCR 402-2. Minimum construction standards must be met or a <br />variance obtained. Standard permit application and work repoR forms are found on the DWR wetuite at httoJ/www.water.state.co.us. <br />Well CorrstruuHlon and Test Reports (GWS-31) must be completed for eadt hole drilled. The licensed conLador or atrthoraed individual <br />must submit the completed forms to this office within 60 days of drilling. <br />Unless a well permk is obtained, the hole(s) must be plugged and sealed within one (1) year after consimctlon. <br />An Abandonment Report (form GWS~) must be submRted for each hole plugged within 60 days of plugging 6 sealing. The <br />monitoring hole acknovAedgementriumber, owners sWcture name, and hole owners name and oddness must be provided on all well <br />permit application(s), wall censtnrction and abandonment reports. <br />The owner of One 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 censtruded in accordance with the Water Weii 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 WRHIN 90 DAYS, PLEASE WRfiE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WRH THE FlLE NUMBER AND FAX THE COPY TO THE OMSION OF WATER RESOURCES. <br />Location: ~~%., SE '/.,Section I~ <br />Township 15~ N/C~Range (09 El~PM ~~ <br />County .~ //c/~ <br />Subdivision ~/R <br />Lot /Jh~ Blk. Nlr+ Flg. ~//k <br />Site/PropertyAddn;ss Te/%~ ('oun~ly ~d 8',3 <br />Hole(s) to be conshuded: Number. <br />Estimated depth t So Ft Aquifer <br />Purpose of Monitoring Hole(s)_ <br />W~ 1Y/ Lever/ Mo,,,t"~~„ <br />v <br />Approximate Date of Construction arc of </ / . Zm~ <br />(Mu~be~at/k/a`r~t 3 days piorro mnshuctlm) <br />Authorized Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />PROCESSFII BY _ _ <br />Additional Conddions <br />