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06-03-08 10:06AM FROM-Colo Div of !later Resources +3038663589 T-155 P.001/001 F-379 <br />RECEIVE0 <br />renrs et NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) g,1p?a <br />6 Plasm type or print legibly In black or blue Ink -JUN 0 3 2008 <br />Colorado Division of NVater Resources 1313 Sherman St-Room 621 Denver CO 80203 ATElI tsounCES <br />Phone BM.86(34W Fax 803.866-35BO Coro <br />AUTHORRED INDMOUAL OR DRILLER <br />Conlact Karen e o Kw.w <br />Company G ow 1* G vi,u =:v%r.. <br />Address 36 w 1/v? o.twn. S+ <br />City, State, ZIp Crav'm x C o 113 2( <br />Phone _°I-la??lb5-`iS9l Fan No. 970 -trtP5 - raab <br />Driller LID. No. (If rppIcable) <br />Vhll Owner(Cllent) Information <br />Name_ l{t, liens 1n sell I i_1C A =wnk. <br />Address IS 7-9 4 41" S*erer_k CA% tQW <br />.1514 q tya y' b a w l W R1 ct% S A 5 <br />welition: }3E y? NE '/,, sedan 10 <br />Township y3@19.Ran9e9 _E/I)PM <br />County K tvA S 4 o.1 <br />Subdivision <br />lot Bilk Fig. <br />Sb/PropertyAddress 2.5 vnr IeS -SC <br />of Lea t(a Q!:44 , Co <br />Noiets) to to wrra w 114: Number 3 <br />E0knsleddapth'` ton Ft, Aqutfor A0+aa%lt0&isl_t <br />Purpose of MonilodnD Hoists) *0 P-OIL06 'Aced.! <br />5aw??tps tirr?v? c4t5Lt?? ,racK fwryr?aho>-IS <br />Apprbximete Dab of ConebuaODn :'avwt. toe aLWT? <br />(Mat be oltsrel3 agnptato wn*uwmr) <br />wellOwnerit Phone (ass) S 5'I - 7Y ffto /?'i r.,.•?.•a.?.-K 22?r <br />tandowvneesNerve: ?uri?a uS Lowv?d VAO*C-gg ur+nu-!• Authorked8tgnshne <br />y ACKNOWLEDGEMENT FROM STATE ENGINEERS FFICE <br />Y S FOR OFFICE USEOMY /L <br />MH- PROCIMSSD EY ?7/? <br />ON _?_._ YVD (o'er ass MD DAMACKNDWLF.OCED (P - 3 - 0 rc <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF 7HE WRITTEN NOTICE OR ACKNOWLEWEMEM' SHALT. BE AVAI At9f E AT THE DRILLING 8ITE, <br />NoOoe was provided 101119 State Englnser at Imst 3 days Pdor to a onstraetion of m0nitotlbg bobservation botapN Comtru %on <br />of the hde(s) mull be completed wbIn80days of the dow noft ww given fo the State Engineer. Testing endforpumping shell not <br />weeW a total of 200 hour untsse.plar wrRtgn approve! is obtained from foe Subs Engbwer, Water elhHo d during !eating ttbi3llMbe <br />used forbeneAclsl purposes. The owner of th9 hole(s) b responsible floc obleinlrrp pennitte) and complying with stInAm and regulations <br />perialla ft to thedIw%a ge ofibAds produced during testing. <br />All work mustcompiy with 1hs tAfabr Well Construction Rules, R OCR 402-Z Mlnin um cortsbraedion standards must be met or s <br />%edwas obtained. Standard permR epplloation and work reporl fbnna am found on the O1MR Ymbalie at bllft?l?lidD'w_ JlY?r s .caw. <br />Weil Conetruatlen oldTestReporta (0WSS11)must be armplaW for each hole drilled. The lioenseo eonimcbroraudwixed brd'widual <br />must subrttt the completed forms to Oft office within 60 days of dd g. <br />UnIns a wen p mnIt to obfalm d, the hole(s) must be plugged and seated whhin one ('l) year af0ar eomtrucBon. <br />An AbandomeM Report (form OW") must be 60IMNW for each halo plugged within 00 days of pluggins & scaling. The <br />monttorl g hole sdarowler?gsnAft number, o m es structure myna, and hots owner's name and address must be provided an all well <br />pormlt appllootlonle), will conatruWan and abendonmerd ropads. <br />The owner of the hole(e) Should maintain records of water quality feblng and ar6mh this data to the State Enal n er upon request <br />A monitoring hole cannot to eonveded to a produclibn waterwell, wompt forpurpoom ofremedtaOon (recovery) or as a porno d <br />deweterNig system. If canstrualed In eCCordsnce with the Thaler Weil Consweilon Rula and poiiales of the State egnser. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT DMICATE THAT WELL PERMR7(S) CAN BE APPROVED. <br />IF HOLES WILLHOTSE CONSTRUCT E.T1 UNDER THIN NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />COPT OF THE ACK1400 E QED NOT]CE iii THE FIL IMIMBISR AND FAX THE COPY TO THE DMBION OF WAT M RE3WRCE3. <br />Additnsl CondtEorra