2011-01-20_HYDROLOGY - M1980244 - Laserfiche WebLink

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i X11-18-10 07:10 F'ROM-Colo Div of Water Resources +3038663589 T-450 P.001/001 F-403 e w"I NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) oslzoos Please type or print legibly In block or blue Ink COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 PHONE 303$86-3581-FAX: 303-866-3N9 Well Owner's Name, Address & Phone if C-4 V4,-0 /0r,,9IXf /2? yjes 7rc F y Landowner's Nam? ?//N/oc r1a Please check one and complete as Indicated Including contact info: O Water Well Driller Licensed in Colorado - Ur- No. O Professional Engineer Registered In Colorado - Reg, No. O Professional Geciogiet per CRS 34-1.201(3) a Other -anyone directly employed by or under the supervision of a Ibensed driller, fegistarod professlonal engineer or professional geoiog{SI Contact / Company ce po ? Address A D, &LO /9? City, state & ZIP ???, Q w ?rrG,,? Phone _ Z19--d&-V0Ye Fax ?Z 9-L& .? Print Name; Signature: Location:?3 _ +/, 411C;, Section Township,XON AS. Range _15? DE DP. county Subdivision, Lot. Blk, Fig (af?applfoable) Site/Property Address GPS Location in UTM format (optiomttl); Set GPS unit to he north, datum NAD83, and use meters for the dlsionce unite, OZone 12 or OZone 13, Fasting Northing # of Monitoring Hotels) to be constructed: Estimated Depth _24V Ft., Aquifer Pu ose of Monitoring 11J?ole(s) n " d e? Q&4 M -V cdcioe ,e7Q.?,0 ra&.wt G?? Anticipated Dots of Construction:.:. Date Notice Submitted: /-, (Must be at least 3 days prior to construction) ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE r FOR OFFICE USE ONLY n` 5 - MH PROCESSED BY *44? Div. = WD Z BAS MD DATE AcKNowi glawD 4-1 P 1 CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. 1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & obeervation hotels). 2) Constnuetiop of the hole(s) must be completed within 9Ddays of the date notice was given to the State Engineer. Testing and/or pumping shall not exceed a total of 200 hours unless prior written apprgval Is obtained from the State Engineer, Water diverted during testing shall be used for beneffolal purposes, The owrwr of the hale(s) Is responsible for obtaining permit(s) and complying with all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402.2. Minimum construction standards must be mot or a variance obtained. Standard permit application and work report forms are found on the DWR webs to at baatJn.?4w.aater ststero u.. Well Construction and Test Reports (GVV341) must be completed 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 well permit Is obtained, the holo(s) must be plugged and seated within one (1) your after conatructiom An Abandonment Report (form QWSA) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owners structure name, and owner's name and address must be provided on all well permit appl1=11 n(s), well construction and abandonment reports. b) The owner of the hole(a) ehail maintain records of water quality testing and submit this data to the State Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WILL, except for purposes of remedlatlon (recovery) or as a permanent dewatoring system, N constructed In accordance with the Water Well Construction Rules and policies of the State Engineer. 7) tF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. space for labels or additional conditions as