HYDRO25195

• Permit No: M1980244
• IBM Index Class Name: Hydrology
• Doc Date: 7/11/2007
• Doc Name: NOI To Construct Monitoring Well
• From: CC & V
• To: DRMS
• Media Type: D
• Archive: No

cwss, NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
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Please type or print legibly in black or blue ink
Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203
Phone [phone] Fax [phone]
AUTHORIZED INDMDUAL OR DRILLER
COntad /rYl rLt / JiriP//C~,le~ ~r7/~io askew/.-~ [mrd,nu~o/
Company CC's Gold n'lin,rr~ ('o,n~„~
Address Po >3ox 191 O
City, State, Zip UIC1vf. ~o toned-, Sso fCtoo
Phone ~l9~fo89 2977 Fax No. 719 ~(a89 - 3Z5~
Driller Lia No. (if applicable)
Weil Owner (Cilent)Information S,1-oTip: OSgT3f-I ~(c
Name CC`V C-,~Id PV~~r„nc ~onnpan.~
Address )~ ~A~K 19 I
IBC) I~IOf{-t~ 3~ ~~(CeF
_~(tc~or Co SGK(o~
Well Owr,els Phone 719 ~(c84 -x477
Landowners Name: CCFUC7oldF1'I,n~nq Con pant/
Location: NE /, NE /,,Section Z~
Township 15 N !a Range c~_ E ~ PM G "'
County ~e/%/
Subdivision
Lat A//A . Blk. A//fr . Flg. A/lf~'
SitelPropertyAddress %c/lei ra<„ly ~•~( 83
Hole(s) to be constructed: Number
Estimated depth ti Sv FL Aquifer
Purpose of Monitoring Hole(s)
W'afc/ Lrvd l1Qen.fcnn
Appro,dmate Date of ConsWdion~ ll/cck "F J,.ly f, zm7
(Must be g least 3 Says P~to mnslutlan)
~ON~~-
Authored Signature
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
FOR OFFICE USE ONLY
MH- PROCESSED BY
Dlv. WD BAS_ MD
DATE ACKNOWLEDGED
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRrtTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIWNG SITE.
Notice was provided to the Stall Engineer at least 3 days prior to consfructlon of monitoring & observation hole(s). ConsWdion
of the hole(s) must lre completed wi9,in 90 davs of the date notice was given to the State Engineer. Testing andlor pumping shall not
exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted dudng testing shall nat be
used for benefidal purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying with all rules and regulations
pertaining to the discharge of fluids produced dudng testing.
All work must comply with the Water Well Constructlon Rules, 2 CCR 402-2. Minimum censWction standards must be met or a
variance obtained. Standard permit application and work report forms are found an the DWR website at htto:/fwww.watersgte.co.us.
Well Construction and Test Reports (C'YY331) must be completed for eati, hole drilled. The licensed contractor or authorved individual
must submit the completed forms to this office within 60 days of drilling.
Unless a well pertnk is obtained, the hole(s) must be plugged and sealed within one (1) year after constructlon.
An Abandonmert Report (form GWS~) must be submitted for each hole plugged wghln 60 days of plugging & sealing. The
monitoring hole acknowledgement number, owner's structure name, and hole owner's name and address must be provided on all well
pertnk applicetion(s), well consWction and abandonment reports.
The trvmer of the hole(s) should maintain records of water quality testing and submit this data to the State Engineer upon request
A monitoring hole canrwt be converted to a production water well, except for purposes of remediation (recovery) or as a permanent
dewatedng system, ff constructed in aecortfance with the Water Well Construction Rules and polities of the State Engineer.
THIS ACKNOWIFDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED.
IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTCE WITHIN 90 DAYS, PLEASE WRfTE, "NO HOLES CONSTRUCTED" ON A
COPY OF THE ACKNOWLEDGED NOTICE WfTH THE FILE NUMBER AND FAX THE COPY TO THE DMSION OF WATER RESOURCES.
Additional Conditions