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GWS•5t NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />03!05 <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 303-868-3581 Fax 303-866-3589 <br />AUTHORIZED INDMDUAL OR DRILLER <br />Contact / stilt .17 C'xx.e.r/ ChrrF ~nJia,n,,,~„it,..,9 lcx~Ydl+.._f„/ <br />Company CC y U Erolcl flkn„~, Cm a,.jr <br />Addness T~7~IIa>< 19I <br />City, State, Zip ()IC4nt fro lorado ~g(o0 <br />Phone X19 J(o~9 - a~i 77 Fax No. -719684' - 3z5~ <br />Driller Uc. No. (if applipbie) <br />Well Owner (Cllent)Infomlation 5;-t~ T-0: G75ABH _8 <br />Name CC. ° / Cho ld JUlivu:l Coruoa~ <br />Address PG fox Ig l <br />loo hlcr4L~ 3'd' Str«t` <br />l.ltc}er (rolorc,clo ~D$LoCI <br />Well Owner'sPhone ~ 71~ JtFS`i -2977 <br />Landowner's Name : CvC` J 6o Id NA.,.,.~ Cto.~.{Jv.r.y <br />MH- <br />Dlv. WD BAS_ MD <br />Location: ~~'/., NW '/., Section ~2-1 <br />Township l5 N('S~Range 64 E/d~PM 6F" <br />County I c!!el <br />Subdivision AS JF! _, <br />Lot N A Blk. N ~ Fig. u[1F <br />Site/Property Address I c l Iz_ ~ C~n{~i I~aoLt 8 3 <br />DATE AcKNOwLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Notice was provided to the State Engineer at least 3 days prbr W construction of monitoring b observation hole(s). Canstluctbn <br />of the hole(s) must be completed within 90 days 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 s II not be <br />used For benefidal purposes. The owner of Itra hole(s) is responsible for obtaining permit(s) and complying with atl roles and regulations <br />pertaining to the discharge of fluids produced during testing. <br />All work must comply with the Water Well ConstruuNbn Rules, 2 CCR 402-2. Minimum construction standards must be met or a <br />variance obtained. Standard permit application and work report forms are found on the DVVf2 wt;bsite at httoJ/www.waterstate.co.us. <br />Well Corretructlon and Test Reports (GW3~31) must De completed for each hole drilled. The licensed contractor or authorized individual <br />must submit the completed forms to this office within 60 days of ddlling. <br />Unless a well pemth is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. <br />An Abandonment Repoli (form GWS~) must be submitted far each hole plugged whhin 60 days of plugging & seal(ng. The <br />monitoring hole acknowledgement number, owners sWcture name, and hole owner's Homo and address must be provided on all well <br />permit application(s), well consWdion and abandonment reports. <br />The owner of the hole(s) shook! 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 pertnanertt <br />deuvatedrg system, if consWded in accordance with the Water Well Construction Rules and polities of the State Engineer. <br />THIS ACKNOWLEDGEMENT OFNOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />IF HOLES MALL NOT BE CONSTRUCTED UNDER THfS NOTfCE WITHIN 90 DAYS, PLEASE WRfTE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WfTH THE FILE NUMBER AND FAX THE COPY TO THE DMSION OF WATER RESOURCES. <br />Hole(s) to be conswded: Number, <br />Estimated depth i Sv Ft. Aquifer <br />Pttrpdse of MonitoringNHlok:(s) <br />Uyc,.1c( ~Jcl 1 v\p.q ~lnr,.~ <br />Approximate Date of Construction Etlf-a( lb Z~7 <br />(Moat ha e4least3Ca)s priorto mitatrtctim) ' <br />~67t~-- <br />Authorized Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />PROCESSED BY <br />Additional Conditions <br />