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MRR-17-2000 16:52 DIU WRTER RESOURCES <br />tlrY/ .,ease ,y ye ,n µ,,,~ ,cg~.ry , ~ u,au n... <br />303 866 3589 P.01i02 <br />nc~tlVtj) <br />I~Gmwlwat6 <br />Na,q o s zoac <br />>h wner's Name C2rP/~_ G.9_Bpr ~, /t C.1'~L GaL7f Mr/rrV(o <br />Landowner's Name Sg~f_ q~s 4•G+°vt' <br />MmTmg Address: lAtrthorized Individual/or Drdlerl <br />Corttact M~SdN ~i~S <br />Company (JLrOP f iJair f /lG7r-L- / DGO Mid ~6 <br />Address P/1 ~>C /9/, ~. <br />City, stare, zip r/Ic~tq~ r h'~fLD -d/9/ <br />Phore 7/9-669- ~ldSfS Fax No. 7/9-/~Y-3 2s C.( <br />DrilleJ Lic. No. (it applicable) NA <br />~so~acss <br />S:w:F EtiGWEfR <br />~rk0 <br />Logtion: Nyt y., ~Ut/ Y., Settion~, <br />Township ~ N~ Range ~ F~( ~~PM <br />County TFt l ~// <br />Subdivision N/k <br />Lot ~ , BIk N!d- ,Fig n/i4 <br />Hale(s) to he Constrtltted: Number Z __ <br />E's'Omated Oepth~-]~Ft. Aquifer (00 <br />FLrpose of Monitoring Hale(s) MOw/iTD?_~ aITf1P_~ <br />Approximate Date of Construction ~p~l, ~,~'JO <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />M H- <br />3'7863 <br />DI _~ GNTY WD / 7~ <br />BAs MD <br />PROCESSED BY ~/ f <br />DATE ACKNOWLEDGED ~~~ ~~ ~O d <br />GROUNO ELEV <br />USGS MAp N <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRiT7E111 NOTICE OR aC1tNOWiEDGE3NE3VT SHALL BE AVAIlABIF AT THE DArt1JNG SITE. <br />Notice was provided to the State Engineer et )acct 3 days prior to construction of monitoring & absarvetien hok(sl. <br />ConetrLetion of the hole(s) must tx completed within 90 days of the date notice was given to the State Engineer. <br />Teeting end/ar pumping shall ne[ exceed a total e} 200 hours unbss prior written approval is obtained tram the State Engineer. <br />Water diverted during testing shell not be used fw beneficial purposes. Tha owner of the holelsl is responsible for obtaining <br />pertnitls) and complying with as rules and regulations pertaining Co the d~seharge of fluids produced during tasting. <br />All work must compty with the Wetar Wall Construction Rules, 2 CCR 402-2. Minimum construction standards must be met o. <br />e variance obtained. <br />Wsg GORSLnJCSien and Test Reports (GWS-311 must be sutunrtted to this oMice by [he licerssed contractor er euttwrixed individual <br />within n0 days of the campbtion of the work. <br />UNass a wall permit is obtaered, the halals) mutt be pWgged end sealed within one It) year after construction. An Abandonment <br />Repon (form GWS•91 must ha submitted within BO days at pWggitq & sealvtg. <br />The owner of the holela) ahoukt maimsirt records of water quality testing end submit this data to the State Enginacr upon request. <br />1'ha monitoring hole number, owner's structure name, and hole owner's name and edtlress must ba Drovided an all well permit <br />epplicatianls), well cof1:4VRlOn and abandonmem reports. " <br />A monitoring hole ten nos be converted to a production water well (other than a recovery well) unlrs the hole or well was <br />originally eorstrueted by a licensed well cons[iVC[ion contraGYOr. <br />TF4S ACKNOWLEDOEMHI[T OF NOTICE ODES NOT INDICATE THAT WELL PEAMITIS) CAN 8E APPROt/ED. <br />Additional Conditions <br />OF WATER RESOURCES-1313 SHERMAN ST-RM 827-DErrvER~O 80203 303-866-358i/FAX <br />