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WS 81 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />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 />6$&N PHONE: 303-866-3581-FAX: 303-866-3589, /' ?/ <br />Well Owner's Name, Address & Phone A NIft CC (Q. Location: Y Section 7 <br />T.L. hrj MiiG5C,-QPL' ZZW 10.box ZSIo7 400NON A.17252 Township 5 ON p6, Range 4 /S ?E Gj(N,_fi_PM <br />Landowner's Name EXXON M0131L CORP. County CARFIELO <br />Please check one and complete as indicated including contact info: Subdivision, Lot, Elk, Flg (as applicable) <br />CJ Water Well Driller Licensed in Colorado - Lic. No. <br />KProfessional Engineer Registered in Colorado - Reg. No. S $ l <br />O Professional Geologist per CRS 34-1-201(3) <br />O Other -anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologist <br />Contact/ Company ALAMO Agougo • Gn-4 5K AGGS <br />Address 715 90f,(U4 W. 5urf1; 34D <br />City, State & Zip GRAUD IR&DA) CIO. 1150(o <br />Phone 970' 2'(Z'qZLO Fax 97D- V5-1134 <br />Print Name: 'rpm L ADAMS <br />Signature: 11 _-0 ".. ,L. <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, OZone 12 or OZone 13. <br />Easting Northing <br /># of Monitoring Hole(s) to be constructed: <br />Estimated Depth I10 Ft., Aquifer 5 6 R OOU E <br />Purpose of Monitoring Hole(s) MONITOR Wkf6(t <br />LEdEI., 11 MAUL ANPtl,Y56 <br />Anticipated Date of Construction:-1-16-11 <br />Date Notice Submitted: -2--Q / Q <br />(Must be at le st 3 dais 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.water.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 />COPY OF THE 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