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11-13-09 U8:4ZAM FROM-Colo Div of Water Resources +3038663589 T-160 P.003/003 F-636 <br />OWS-51 NOTICE OF INTENT TO CONSTRUCT NION1118 <br />cameos KIN LE(S) AVWCX <br />Please h'a or print <br />type reguAY In black or blue inkwv4z , kr& CES <br />i?7? ENGI y yes <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMATN ST-RM 821-DEFNVER CO.6203 <br />PHONE: 303.wI3, 3581-FAX: 303.868-3588 <br />Well Owner's Name, Address A Phone Y „I <br />1.91 141G 4 .p <br />Lartdowner's Name r-e-"a(JJ <br />" t, 0 <br />Please check one and complete ds indicated Including oorriect Info: <br />CI Water Well Driller Licensed In Colorado - Lic. No. <br />D Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist per CRS 34-1-201(3) <br />Other -anyone directly em oyred by or under the aupervielwl of a Iloensed diner, <br />registered profeetionar engines or proees <br />n <br />tonal gawo t <br />Contact / Compan <br />Address D BO <br />City, state & ZIP <br />Phone e0e0'R- &9& Fax 2- -A" <br />Print Name: _ 111mb ///1 /'? <br />Signature; <br />Location: L?t/ Y4 62L/ %, Section <br />Township.LC N ®5, Range jo [3E ?o' ?rPM <br />County r-ewwv <br />Subdivision, Lot, Sk, Fig (as likable) <br />SUProperty Address 7-guar 60AT <br />GPS Location in UTM format (optional); <br />Set GPS unit to true no*. dattret NAD83, and use meters for <br />the distance unb, ?Zone 12 or ?Zone 13. <br />Easting Northing <br /># of Monitoring Hole(s) to be Constructed: <br />FAUMated Depth m AQuftr <br />Purpose <br />W4 4r", of Monitoring hole(s) <br />! T ?Pr.? <br />Anticipated Data of Construction: <br />Date Notice Submitted: ,_//-/x - <br />(Musi be at least 3 doys prior to construction) <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />- MH PROCE33ED BY <br />Div. <br />1) <br />3) <br />4) <br />5) <br />9) <br />7) <br />WD BAS MD DATE ACKNOWLEDGED <br />CONDITIONS OFMONITORINO HOLE ACKNOWLEDGEWNT <br />A COPY OF THE WRn MN NOTICE OR ACKNOWL WGEMr2NT SHALL BE AVAILABLE AT THI! DRILLING SITE. <br />Notice Was provided to the State Engineer at leset 3 days prior to construction of monitoring a observation hole(s), <br />Construction of the hole(s) mull bo completed within 90 days of the date notice was given to the State <br />"now, shah not exceed a total of 200 hours unless prior written approval In obtained from the Scats Entalnew.WatediTesting andlor <br />verted during testing <br />atoll no3 be used for baneticiel purposes. The owner of the hole(s)13 responsfble for obtatning permit(s) and complying with all rules and <br />regulations pertaining to the discharge of fluids produced during testing. <br />All work must comply With the Water Well Construction Rtdes, 2 CCR JIM, Minimum construction standards must be met or a variance <br />obtained. Standard permit application and work report faints are found on the DWR webelte at kae:/(r m wnt_er.e tn?l[Up.m. Well <br />Construction and Test Reports (OWS-31) must be completed for each hole drilled. The poensed oontracWr or authorized Individual must <br />submit the completed forms to this oftlce within 00 days of monitoring hole completion. <br />Unless a well parmit Is obtained, the hote(s) must be plugged and settled WltNin one (1) year after constructlon. An Abandonment <br />Report (form GWS-9) must be submitted within 60 days of plugging S seeding. The Move MH acknowledgement number, owners <br />structure name, and owner's name and address must be provided on all wel Permit appllcatfon(s), well construction and abandonment reports. <br />The owner of the hole(s) &hall maintain records of water quality testing and ®ubmit huts date to the State Engineer upon request, <br />A MONITORING HOL I CANNOT BE COWERTED TO A PRODUCTION WATER WELL, except br purposes of remediatikm (recovery) <br />or as a permanent dim attiring system, If constructed In accordance with the Water WON Construction Rules and policies of the State <br />Engineer. <br />' '" . ' ' ' • , lira!; IT-MC.:T'ED UNDER THIS NOTICi? WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUt:'t4-A-", •r. <br />+; - ":"I I I.MM-11 NOTICE WITH THE Fitt: NUMBER AND FAX THE COPY TO THt3 D1%g3LON OF wATFi; R-S01 tr ot- <br />THIS ACKNOWLEDOMWaNT OF NOTICE DOES NOT INDICATE THAT WELL PF.RtyttT(S) CAN BE APPROVED. <br />(use above space rot IaCW$ or additional conditions as