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M?? iv - ,sv <br />8ws-51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please type or print legibly in black or blue ink r? <br />Si P 0 'r 2i'M <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203icri c r :eclarnation, <br />PHONE: 303-866-3581-FAX: 303-866-3589 fM;ning and Saiaty <br />Well Owner's Name, Address & PhoneCR)Adze-( pA k v` I'fcTDR ,040 <br />?LK/e!G- ?. • ?°??o /9/ ?vo? CO ?a?'6o? ?_ 7J ?C?9- ?.9 )7 //'? <br />Landowner's Name CR?Pd?e Ckt?F ,x y?nye <br />Please check one and complete as indicated including contact info: <br />O 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 />9 Other -anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologist ?f <br />Contact/ Company LlARIC y1'tm w/ kco I/ /,y?,,.? Cp <br />Address Qox Al <br />City, State & Zip X/G7D,?. 60 "610 // d pp <br />Phone -'219- 9- 0'00P Fax -7//- CorP1-? ? <br />Print Name: //z/91" <br />v/VivD?// <br />Signature: <br />Location: 16, , /. -f/^ /. Section <br />Township /f ON Lys, Range W 9 ?E &W, 6 PM <br />County <br />Subdivision, Lot, Blk, Fig (as applicable) 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, OZone 12 or []Zone 13. <br />Easting Northing <br /># of Monitoring Hole(s) to be constructed: <br />Estimated Depth -]s O Ft., Aquifer <br />Purpose of Monitoring Hole(s) I <br />?g a,/,VD <br />11V,47tW I t>O,?] TOie//NA <br />Anticipated Date of Construction: ?9-& Vo <br />Date Notice Submitted: o? d 9 ` eqt7 <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 ILtti)://www.watei-.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 owner's 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 BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />c;OPY OF T14E 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)