2011-01-20_HYDROLOGY - M1980244

• Permit No: M1980244
• IBM Index Class Name: HYDROLOGY
• Doc Date: 1/20/2011
• Doc Name: NOI to Construct Monitoring Wells
• From: CC&V
• To: DWR
• Permit Index Doc Type: Hydrology Report
• Email Name: BMK
• Media Type: D
• Archive: No

12-03-10 15:52 FROM-Colo Div of Water Resources [phone] T-488 P-002/002 F-518
owsal NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) ,
oerzooe Please type or print legibly In black or blue Ink
COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203
PHONE [phone]-FAX 303.866%689
Well Owner's Name, Address & Phone e--e-4V G Ole //„?./1 '(p
Lao eo D
B/
Landowner's Name Wi dL4.0 174A//N4 CV
Please check one and complete as Indicated Including contact Info:
? Water Wall Driller Licensed In Colorado Llo, No.
? Professional Engineer Registered in Colorado - Reg, No.
Profasslonal Geologist per CRS 341401(3)
OrOther -anyone diroclry employed by or under the supmWon of a licensed drlMer,
registered professional engineer or al goologlat
Contact / Company ,174d. 1?,rF,&e j1
Address /01 4. = A/
city, state & Zip 1110y.4, era OP-400% 10
Phone 7 Fax 2/2- 9-.,y La
Print Name:
Signature:

Location: = Y. "'/,. Section
Township Z-ft!N X8, Range DE WN, 6'af?M
bGt`'
County
Subdivislon, Lot, Sl x, Fig (as applicable)
She/Property Address Gr/
BPS Location in UTM format (optional):
Set OPS unlt to true north, datum NA083, and use meters for
the distance until, UZone 12 or (Zone 13,
Fasting Northing
# of Monitoring Hole(s) to be constructed:
Estimated Depth 's-at., Aquifer
Purpose of Monitoring Hole(s) __7b d e-j6p j e +o
Anticipated Date of Constructlon:
Data Notice Submitted: z;.-
(Must be at least 3 days prior to conmru don)
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICP
FOR OFFICE USE ONLY
MH PROCESSED BY g
Div, WD 1 BAS MD DATE ACttNOWLEDGED 1 L
CON0171ONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OFTHE WR rMN NOTICE OR ACKNOWLEDGEMENT SHAD, SE AVAILABLE AT THE DRILLING SITE.
1) Notice was provided to the State Engineer at least 3 days prior to constrix9on of monitoring & obsenradon hole(s).
2) Construction of the hole(s) most be com plated within 00 days of the date notice was given to the State Engineer. TwUng and/or
pumping shall not exceed a total or 200 hours unless prior written approval Is obtained from the State Engineer, Water diverted during testing
shell not be used ror beneficial purposes. The owner of ft hole(s) is responsible for obtaining permlt(s) and complylrtg with all rules and
regulations pertaining to the discharge of fulds produced during testing.
8) All we* must comply with the Water Wall Construction Rules, Z CCR 40-1 Mlnlmum construction standards must be met or a variance
obtained. Standard permit appllcatlon and Work report forms are found on Me DWR webslle at ltnn:llwnw.w.tar.Rtata ca.ue, Well
Consbuc& n and Test Reports (OWS-31) must be completed for each hole drilled. The licensed contractor or authorized individual must
submit the completed forma to this office wl[Nn So days of monitoring hole completion,
4) Union a well permit Is obtained, the hole(s) must be plugged and sealed within one (1) year after oonstruction. An Abandonment
Report (Form GM-9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's
structure name, and owner's name end address must be provided on all well permit application(s), well construction and abandonment reports.
5) The owner of the hole(s) shall maintain records of water quailty testing and submit this data to the State !Engineer upon request.
8) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER 1NEIJ- except for purposes of remediation (recovery)
or as a permanent dewatering system, If constructed In accordance with the Water Will ConsbwAon Rules and pollofes of the State
Engineer.
71 IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 9o OAY% PLUME WRITE, "NO HOLM CONSTRUCTED" ON A
COPY OF THE ACKNOWLEDGED NOTICE WITH THE ME NUMBER AND FAX THE COPY TO THE 0IV181ON OF WATER RESOURCES,
THIS ACKNOWLEDGEMENT OF NOTICE DOLES NOT INDICATE THAT WELL, PMMIT(S) CAN BE APPROVED.
epaea for labels or additional cw4dons a9