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06-03-08 10:06AM FROM-Colo Div of Water Resources +3038663589 T-155 P.001/001 F-379 <br />RECEIVEn <br />cvvs.el NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oaoa <br />Please lype or print legibly In black or blue Ink ..SUN 0 3 20M <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO BD203 FEDAtsoLMEES 61 ftfn <br />SiATF EN6?HL[P <br />Phone 3"o-SM Fax 303-866.3589 L°ln <br />AUTHORIZED iNDIVIDUALOR DRILLER <br />Conlect KaLrw?ea% KL.•z <br />Company Gewt* Gvuof dr.. <br />Address 36 w iM w'" S+ <br />City, state, Zip ca," M x f. U -R 15 a <br />Phone 0119 f q01- 9 Sgt- Fax Na.__910 - er (o s- - t lid (D <br />Driller Lic. No. Of applicable) <br />Well ownar(Client) Information <br />Name K!A*- _Abrm6&vw / LKA <br />Address 15 7 a 4 41 1^ g+ceak e.+ NW <br />GnCk K r b 0 f_w1? c1'83A5 <br />Lot:attt n: l.1E Y., NE •/,. Sadbri 10 <br />Townshlp X13®/S.Range_tj EIG)PM <br />HunSrD a?G <br />County <br />Subdivision <br />Lot elk - Fla. <br />SWPropertyAddMn 2.5 mr 1a6 •S£ <br />of t_? Kd Cct'tA " CO <br />Hole(s) to be cormtrueted: Number :3 <br />EsUmaWdap n20 K Aquifer No+'LaS11 V, <br />Purpose of Monitoring Hole(s) fins e01L26 wrl*f <br />ne !t neles ?V? chyyiv?a Tag; CswvvuchoytS <br />Apprbxlmate Date of ConebuoL'on ?'a?nc, tDr aOdSj <br />(M>atboalreaeL7dipnpfortowMine im) <br />Wes Ownerb Phone (8S3) $ S/ r 7 Y $(o <br />LandownseaName: 3ursc-Lr CA t.awr3 V?4oKa?,n,naou? Au ?ft?y <br />?re <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE A <br />q7 S Y F FOR OFFICE USEONLY <br />MH• PROCwst2D BY <br />Dw -4.- VW (o t3AS MD l3AXACM0%na.M)GED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF 711E 1AiIMEN NOTICE Olt ACKNOWLEMEMENr SHALL BE AVALABLE AT THE DRRUNO 8rrE. <br />NoQee was provided lo lie Btate Engineer at tegsl3 days pda to construction of manltoting & observation bole(s). Construction <br />of the hole(s) mull be computed whin 60 avs of the date notice was given to the State Engineer, Tesft andlarpuffoin9 shall net <br />exceed a OWl of ?AD hours tnless.prlar.wdtl6n approval Is obtained from the Slate Engineer. WAtor dfvsrted during le*V fiWj Oi be <br />used for beneDdal purposes. The owner of the hale(s)is weponsible forobtaining pennlt(e) and mmpiylng with ep rinse and regulations <br />pertaining to thedlecharge oflulde produced during tenting. <br />AN woylE musteornpty with lihs Water Well Con drawtion Rules, 2 OCR 404 Minimum t:ortsW cNon etertdsnis must be mat ore <br />varianoa obtained. Mended permit epplioation aW wo* report terms are found on the DWR vreballe at hteny tarprat$.oo.w. <br />Wall CmwtructisnandTest Reports (OV93-31) mist be dornpleted for each hole drilled. TNI03new=nimcbraraudw medlndL*ial <br />must subltdt the completed fotma to this office within 60 days of drilling. <br />Unless a Wan permit Is obtalned, the hole(s) must be plugged and sssied within one tip year aftr oonstmdlon. <br />An Abodonment Report (form GiWB-e) must be subtnNtad for each hole plugged within 80 days of plugglro & oft. The <br />monitoring hole adaLwutadgarrrent number, owner's structure name, and hole owner's name and addwas rat at be pm4lded on all well <br />Pamillapplloetlon(e), well construction and abandowent reports. <br />The owner ofthe hole(s) should maintain records of water quatltyE lwbV and sLbmh this data to the State Engineer upon request. <br />A monitoring hoio cannot be. careened to a productlon waterwell, oompi for purposes of remedlatlon {neomwy) area a penmenard <br />deNatsrtng systemr it constructed M accordence vAth the ftier Well Canalruction Rules and policies of the Sta Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT WICATE THAT WELL PERMIT(S)13M BE APPROVED. <br />IF HOt M Wa.LNOTBSCONSTRUCTEO i INDER, THIS NOT= WITHIN Ott DAYS, PLEASE WRITE, -NO HOLES CONSTRUCTED" ON A <br />COPYOF THE ACKNn3WLE r3ED NOTICE M H TFIE ILV NUMBER AND FAX THE COPY TO THE DWON OF WATIFi RESOURCES. <br />Additional Conditions