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<br /> <br />f <br /> <br />L~ <br /> <br />J <br />II-DB-B9 D5:D'oP,N FROM-DIVISION OF WhiER RESOURCES 3J3Diiii222e i :ci P.ui,ui r-eta <br />cws.st NOTIr:E Or INTENT~TO CONSTRUCT MONITORING HOLE(S1 <br />w9T Please type or print legibly in 6Tack ink <br />APPENDIX C <br />Well Owner's Name l ~ n a~e.~- !~ a-_a= v -, -~ wc,.. <br />landowner's Name t~~ ~. + ~ o _e v - .,.. _ <br />Meil'mg Addr th rlx /or Drilled <br />Genteel <br />CompenY ~iS ~.~_ ~r~4e1Q-ti ~554~ ~~~. <br />Address '~?.Z ~h U e,~~s~ ~'ln<o <br />C1ty, ~te, ZJp l_.~ • ~ P + • ~ w e, Lb ~ G l l fl <br />Phone /1p3190b-~SS'~LFa:No. C3oj~$OL~€ITS3 <br />Date of Corytructian <br /> <br />1 <br />L~ <br /> <br /> <br />~l <br />1 <br />LI <br /> <br />1 <br />Driller Lie. No. fit applitablet <br />MH- 3'7332 <br />DIV. I CNtI' WD <br />Bas MD <br />1 NOV 0 815199 <br />PZ-2b--PW <br />Location: ~t~y., Sf ;t, Section Z~ 1 <br />7awnship ~~, Range ~_ ~ ( PM <br />Courtly ... t \ r) o i <br />Subdivision I <br />Lot ,elk , FIg ++~ <br />... !~. ~ I <br />{~ <br />PaaOCESSED <br />DATE ACKh <br />GROVNG <br />to be Cpnatructea: Nurt'ber <br />i <br />;ed Dept~t~.g k, AQuifer Alluar~~ <br />t of Monitoring HdD(s1,_'.e Ilia ~ <br />ER'S OFFICE <br />DOED~ <br />uscss M P J <br />CONDCTIONS OF MONt70RING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRRTEH NOTICE OR ACKNOWLEDGEMElV7 SHALL BE AVAl1ABLE AT THE DRILLING SITE <br />Neske was provided to the State Enpinen a: iaatt S days briar to ceretnetion of monitoring S obrervat~an hoteDa. <br />Conctrvetion o} eho holeiej mutt ea evmpletea w;tnin 90 Cays of the oats net:ee was given to the Stets Engineai. <br />Testing andlor pumainp shall not otceed a total of 200 hours unless prior written oppr9val is obtained from the State Engineer. <br />Water diverted during teasing ah no be used far beneficial purposes. 7ne owner of t~fe nclelsl i9 reaponnble fix obtaining <br />permit!:! end complying with all rules end legulations partaininp to tlfe di:eharpe of 11Vi s pre ducetl tl~nna testing. <br />wtl wont muss comply wRA she water Well Construction Rotes. 2 CCR x02.2. M;n;mu eonstr.,ct;on standards must De mr. ar <br />a wrbnc• ot:tainad. <br />Well Centtruction and test RepoRS IGWS-371 mVSt oe submitted to this oftia6 by the ioenesd t:onsrae[ar or eutnartsed ind',Jdual <br />within 60 days of the comp~otion of the wort. <br />Unmss a was pnm',t is ob:e~nod. the hole(s) mast be plupyed and seated wltnin ens (1 you attar con:; :coon. An Abandonment <br />Re art !form GWS91 must be svSm~tted w,th;n 60 da s of to ~ <br />P y p Aging 8 leafing. <br />Tns owner of the holelsl enoa:d maintain /scores of water quality testing and auDmit t is doss to she State Engineer upon reetueat. <br />Tne monharinp hole number, owner's at/uetYre name. and !Iota owns: L name and 0ed~e [a mus[ De prot•;7cti on all well permit <br />aDDl,cetton(sl, weal eonstn.~aion and abandonment reparte. <br />A monitoring hate can not be converted to a preduetien water we!{ !other enan a reeevfry well! unless the hole Or welt was <br />orlpinalty eons[r~ctad Dy a licensed weA eonatructivn evntraGter. <br />iHts aCKNOwltzacEMEM op NoTtcE DOES NoT INDICATE THAT Nf:LL PERMITIS CAN BE APPROVF~. <br />AddMOnat Conditions; <br />I <br />ACKNOWLEDGEMENT FROM STATE <br />FOR OpF~CE USE Oivlr <br />, <br />1 <br />