2009-11-17_HYDROLOGY - M1980244 - Laserfiche WebLink

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11-1J-us Uts:41AM VKUM-L;010 uiv OT water Resources +3U3tititi35H9 T-160 P.001/003 vF-636 I Gwa6t NOTICE OF INTENT TO CONSTRUCT MONITQR!N1• jFA otrme ?E(S) Please typ We or pant legibly In black or blue ink r0N? M?4F N -7 3V COLORADO DMSION OF WATER RP-SOURCES-1313 SHERMAN ST-RM 821•DENVER„00,-e=3 PHONE: $03.866,MBI-FAX: 3034wa.8689 Well Owner's ??Nggame, ddnesa d, Phone Landowners Name C? ?O?!?///??i,?_` Please check one and complete as Indicated Including contact Irtb: Water Well Driller Licensed In Colorado - Lb, No, 0 Professional Engineer Reglatered in Colorado- Reg, No. Q Professional Geologist per CRS 341,201(3) f { Other ,anyone d reotty ernployed by or under the auporvkllon or a Ilnensod drftr, ?alstared Professional engineer or pronal geobq Contact / Company ?pI (moo /? Address -9 CO City, State a Zip / e- v o6 ? Rhone 2/2 - 10Fax g_?_) C-4/ Print Name: / 74on Signature: Location: J G / ? y? Section Township ?[IN gfS, Ranee rZoo!"DE L W,,g7OM County `!:!R Subdivision, Lot, Slk, Fig (ae 4pillicable) SftalProperty Address j- G GPS Location In UTM format (optional): Sat GPS unit to true north, datum NA089, and use meters for the distance units. MZone 12 w nZone 13. Easting Northing p of Monitoring Hale(s) to be constructed: EsffnWad Depth 2j,Ft„ Aquifer Purpose of Montt ring HOie(s -y--s[,a'e2 SON ,.Z 12,1.G- !W- Andclpated Date of Constmetjon: ?/- -0 ! Dane Notice Submhted: -11-12-of (Mull be at least 3 days prior to construotror) ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE f / CT q I G? FOR OFFICe USE ONLY "l MH PROCESSED BY ` Div. WD _J L SAS MD DATE AClauowLmaep ? (" (3 • 0 CONDITIONS OF MONITOPJN(3 HOLE ACKNOWLEOGEttAEN r A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGMMT SHALL BE AVAiL AW AT THE DRILLING SITE. 1) Notice was provided to the Stabs Engineer at least 3 days prior to cpnstructlon of monitoring S observadon hole(s), 2) Construction of the hole(s) must be completed within 9 a s of the dale notice was 8rvan to the State pumping shell not exceed a total of 200 hours unless riot EVnew, Testing and/or prior written approval is obtained from the State Engineer, Water diverted during testing &h all no be used for beneficial purposes, The owner of the hole(s) is responsible for obtaining permit(s) and complying with aU rules and regulations pertaining to the discharge or fluids produced during tes*V. 3) All work must comply with the Water Well construction Rules, 2 GCR 40" Minitmum construction standards. must be met ore variance obtained. Standard permit apppoaWn and worts report brine ate Found on the DWR websits at blta:N,lvxrw ?,M. Construction and Test Reports , acad. Well (OWS.31) must be 00"9k fed for each hole drilled, The licensed contractor or authorized individual must submit the completed forms to this office within 60 days of monitoring hole completion. 4) Unless a we" permit is obMhW, tits hole(s) must be plugged and seated within one (1) year after construction. An Abandonment Report (form GWS..9) must be eubmltted within 6o days Of plugging & sealtrmg. The above MH aqutowledgement number, owner's structure name, and owner's Hama and address must be Provided on all well permit 8) The owner of the hole(s) shalt nrafntalin records of crater appiicadon(s), wep construction and abandonment reports. quality testing and submit ails data to the State Engineer upon request 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WSI.L, except for purposes of rarnediatlon (recovery) or as a permanent dewatering system, if constructed In accordance with the Water WON Construedon Rules and Policies of the State Engineer. r ' 'r r 11?rtl-- Ten UNDER THIS NOTICE WITHIN 90 DAYS, PLEASC WIZ TE, "NO HOLES C014slrn1+, ft'r r ,fir tr ?':1 F 1s. Grp NOTICE WITH THE FILQ NUMI3ER AN13 PAX TH8 COPY TO THE DIVISION OP pt Ail-Y rzr.:e;a gr1:1 r,. THIS ACKNOWLEDpMBNT OF NOTICE DOES Nor INDICATE THAT WELT. PERMIT($) CAN BE APPROVED. above spate for labels of addloonal conditions as