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Gv07,t, 7-4b t??/7 ' 16-S;00 <br />8ws-58 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please type or print legibly in black or blue ink <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 <br />PHONE: 303-866-3581-FAX: 303-866-3589 <br />Well Owner's Name, Address & Phone CRIPPLE BS 4 tlc?-DR aca Location:' sE %/. ? /,, Section /7 <br />lyiivc ?o. P ?o/9/d wod CO?o?(,?• 7?9 ??y_ a 9 )) Township /S ?N Q'S, Range 6 9 ?E 21V, __6_PM <br />Landowner's Name6RiP?E R,ez.j roto ?iN/?'Q ?0, County TEGG?R <br />Please check one and complete as indicated including contact info: Subdivision, Lot, Bik, Fig (as applicable) N /F <br />? Water Well Driller Licensed in Colorado - Lic. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist per CRS 34-1-201(3) <br />[E Other -anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologist <br />Contact/ Company _/ /ARK tl ma y/ /CCd l/ dam 4,vi,,•4 Uj <br />Address /01_QOx <br />City, State & Zip a oKG7W e . 60 A0A10 Phone X9-4(? y04 ??Fax 7d-/a <br />?? S' 14-V <br />Print Name: ?,VI a ?/_ <br />Signature: <br />Site/Property Address /? <br />GPS Location in UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />the distance units, []Zone 12 or []Zone 13. <br />Easting Northing <br /># of Monitoring Hole(s) to be constructed: <br />Estimated Depth _S-d0Ft., Aquifer <br />Purpose of Monitoring?Htole(s) Wi1 0V"4 <br />G??Tb7Q / /Di?/ TmR/N? <br />Anticipated Date of Construction: tJ7"-?? C/Cr <br />Date Notice Submitted: ?d -oZ /•-?? <br />(Must be at least 3 days prior to construction) <br />/ ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />- MH PROCESSED BY <br />Div. WD BAS MD 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 />1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). <br />2) Construction of the hole(s) must be completed within 90 days of the date notice was given to the State Engineer. Testing and/or <br />pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing <br />shall not be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying with all rules and <br />regulations pertaining to the discharge of fluids produced during testing. <br />3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum construction standards must be met or a variance <br />obtained. Standard permit application and work report forms are found on the DWR website at htto://WWW.WRter.state.co.us. Well <br />Construction and Test Reports (GWS-31) must be completed for each hole drilled. The licensed contractor or authorized individual must <br />submit the completed forms to this office within 60 days of monitoring hole completion. <br />4) Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment <br />Report (form GWS-9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's <br />structure name, and owners name and address must be provided on all well permit application(s), well construction and abandonment reports. <br />5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request. <br />6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediation (recovery) <br />or as a permanent dewatering system, If constructed in accordance with the Water Well Construction Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT RE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />(Use above space for labels or additional conditions as needed)