Laserfiche WebLink
kI/lf tt- -,4t G?L - /D-7so <br />GWS.st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />08/2008 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/PaLr _K"AgWr 4 1/o_ 4R R oco Location: ? %, _/(/L? %, Section oL/? <br />/N//VG ?4. P Qryo/9/• ?vD?? C0?o?6O?' /??orp9-a 9 )) Township IT?N 93b" Range f,/)y ?E [90W. t? PM <br />Landowner's Name )PAbe t?R6,WL, County cG?-E <br />Please check one and complete as indicated including contact info: Subdivision, Lot, Bik, Fig (as applicable) <br />? Water Well Driller Licensed in Colorado - Lic. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />?1 Professional Geologist per CRS 34-1-201(3) <br />L7 other -anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologist <br />Contact/Company 1 A' ,ek VAMIrv/ 1e_e-d Y Lo e,yi,,.G 6 <br />Address IQQ QOXI ?9? <br />City, State & Zip _ TJ? PO?649 <br />p <br />Phone 719-6?9- y0ylP Fax 7/9- a,9-SIE <br />Print Name: <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 75-OFt., Aquifer <br />PurposI.f Monitoring Hole(s) ?2oyva ,/ <br />/ / /)o?? role/./',? <br />Anticipated Date of Construction: QJ-0? t? <br />Date Notice Submitted: 00 ?_ d-o 1000 <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 htti)://www.watel-.statc.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 />above space for labels or additional conditions as needed)