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cws.st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oyos <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 303-865-3589 <br />AUTHORIZED INDMDUAL OR DRILLER <br />_~ /~ <br />Contact ~l/HM Lome.r/G~ic/ £in.l/,rm,m"..~~ Cuo~ct..wlr/ <br />Company _CCTI/ Cold P4L,,,.,.. ft.w <br />Address Po 3oK 191 <br />City, state, Zip ~lrr_F„~ , Co(or~do tFC1$(nU <br />Phone ~7r4~[,8b-x977 Fax No. 7lci~lcCs~r-325`/ <br />Driller Lic. No. (if appliceble) <br />Well Owner (Client) Information S, ~ S0: O SArs fl ~7 <br />Name CC t y Ctdc) (M,n,v,5 loa.[lany <br />Andress 7d 13~x ~ `~ 1 -- <br />loo tJo~N. 3 s~-r~ F <br />Well Owners Phone -(I`f / (n 85 - 2477 <br />Landowners Name: <br />MH- <br />Dlv. <br />WD BAS MD <br />DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRTITEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIW NG SITE. <br />Notice was provided to the State Engineer at least 3 days prior to consWction of monitoring & observation hole(s). ConsWction <br />of the hole(s) must be completed within 90 davs of the date notice was given to the State Engineer. Tesdng 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 benefidal purposes. The owner of the hole(s) is responsible for obtaining pertnd(s) and complying with all rules and regulations <br />pertaining to the discharge of Ouids produced during testing. <br />All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum constuction standarcls must be met or a <br />variance obtained. Standard permit application and work report forms are found on the DVN2 website at htto:/hvww.water.state.co.us. <br />Well Construction and Test Reports (GWS~1) must be completed for each hole drilled. The licensed centradw ar authored individual <br />must submit the completed forms to this office within 60 days of drilling. <br />Unless a well permit is obtained, the hole(s) must be plugged and Beaked wffhin one (1) year aPoer construction. <br />An Abandonment Report (form GWS~) must be submitted for each hole plugged within 60 days of plugging b sealing. The <br />monitoring hole acknowledgement number, owners sWCWre name, and hole owners name and address must be provided on all Weil <br />perm8 application(s), well construction and abandonment reports. <br />The oumer of the hoe(s) should maintain records of water quality testing and submit this data to the State Engineer upon request <br />A monitoring hole pnnot be converted to a production water well, except for purposes of remediation (recovery) or as a permanent <br />dewatedrlg system, if consWded in accordance with the Water Well Construction 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 WITHIN 90 DAYS, PLEASE WRRE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WRH THE FlLE NUMBER AND FAX THE COPY TO THE DMSION OF WATER RESOURCES. <br />SE 5~ i7 <br />Location: ,W-~ _'/., P*bd' '/., Section ~F <br />Township ~ N /(Sj Range o E ~M <br />County `re (Cer <br />Subdivision tilA , <br />Lot A)~iF . Blk. N /k Flg. A~~F~ <br />Site/PropertyAddress Tcf(.e~ Cou..{y ~cr,d 83 <br />Hole(s) to be censWded: Number ~ <br />Estimated depth x So Ft. Aquifer <br />Purpose of Monitoring Hole(s) <br />(~10.kr Le~tl Mon.~„w~, <br />( <br />Approximate Date of Construction Ldeall "r ~,.lv , zec7 <br />(Must be ri least 3 days pderto oanMnclion) <br />/!~ C~ <br />Authored Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />_ _ PROCESSED BY <br />Additional Cordifions <br />