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II -ua- Iu <br />ows-st <br />08I200a <br />ub:ub rKUM-t:olo Uiv of Water Resources +3038663589 T-409 P.002/002 F-303 <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOD(S) <br />Please type or print legibly In black or blue ink <br />COLORADO DIVISION OF WATER RESOURCES•1313 SHERMAN ST-RIM 821-DENVER-00.80203 <br />PHONE: 303886.3581-FAX: 303-866.3589 <br />Woll Owner's Name, Address & Phone Cc a 1/4-040 / .W/111G r19 Location: % SC V., Section / 7 <br />??B?OX ?9? L ?1GT142i tfL7 0'0 Township b- ON P'S, Range _6,9 )]EZW, J5-OM <br />La do owner's Name Ccy YDaai?/ (C? County <br />Subdivision, Lot, Bilk, Fig (as applicable) N <br />Please check one and complete as indloaWd Including contact info: <br />Q Water Well Driller Licensed in Colorado - Uc. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist per CRS 34,1-201(3) <br />4Other -anyone directly employed by or under the supervision of a licensed driller, <br />laterad professional near or profasMonal geooll "lei. /? <br />Contact / Company A l?t?dai /C -o 6r-qr.-44, Co, <br />Addmas /--, v? g_Q rl 7/ <br />City, State & Zip ;!2 CO ?cl <br />Phone 7/9, v?? ?- ?r2 Fax 71 9 ' Gd p -74:a <br />Print Name: <br />Signature: <br />A99 ?- <br />She/Proporly, Address &is 64yw 2o4D <br />GPS Location in UTMI format (optional): <br />Set OPS unit to true north, datum NA083, 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 74'6t, Aclutfer <br />Purpose of Monitoring Hole(s) <br />T/+vo ryS.G6?GE92_ / /JN? i d?ina G•2c» <br />Anticipated Ode of Construction: <br />Date Noires Submitted: -ne vo <br />(Must be at laasi 3 days prior to consi uclion) <br />tl - ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />i, q u 6 $ FOR OFFICE USE ONLY <br />"G l f f7 -- w MH PROCESSED BY <br />Div. `- WO 17*' BAs MD DATE ACKNOWLEDGED f?l " ' l0 <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITrpr NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SME. <br />1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & obasemation hole(s). <br />2) Cons tetlen of the hole(s) must be completed within W 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 />pplilI p? be used for beneficial purposes, The owner of the hole(s) Is responsible for obtaining pamdt(s) and complying with all rules and <br />regulations pertaining to the discharge of fluids produced during testing. <br />3) AN work mitttt comply with the Water Well Construction Rules, 2 CCR 402.,,4. Minimum construotion standards must be met or a variance <br />obtalnsd. Standard permit application and work report forms are found on the DWR webslte at kWuL mM,3Mt0r.sf+foxo.Va, than <br />Construction and Test Reports (OM-31) must be completed for each hole drilled. The licensed contractor or authorized individual must <br />submit the completed Forms to this of ice within 80 days of monitoring hole completion. <br />4) Unless a well pwmlt Is obtained, the hole(s) must be plugged and waled wflhin one (1) year aftorcorwtructlon. 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 />6) The owner of the hole(s) shall malmtain records of water quality testing and submit this data to the State Engineer upon request. <br />6) A UONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remedlatfon (recovery) <br />or as a permanent dswatering system, If constructed In accordance with the Water Well Constnxtlon Rules and policies of the State <br />Engineer. <br />t) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 PAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTiCS WITH THE FILE NUMBER AND FAX THE COPY TO THE WISION OF WATER MOURGES. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT IN131CATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />spats for labels or additional conditions as