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GWS-51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />08/2008 Please type or print legibly in black or blue ink 01,4811-12 <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 <br />PHONE: 303-866-35B 1--FAX: 303-866-3589 <br />Well pOwner's ?Name, QAddres & Phone ?C>? y G ?7LD / / 4 ?Q Location: /1//^/ y. /11(4' y, Section 122-1 <br />_ <br />/ ?, yCT??'P/ c? ,?Di?bO Township ?.S ?N ?S, Range ? ?E,0W, ?u PM <br />Landowner's Name CC pL // z?-.0LO p County T• ?_2_ t 2 <br />Please check one and complete as indicated including contact info: Subdivision, Lot, Blk, Fig (as applicable) <br />? Water Well Driller Licensed in Colorado - Lic. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist per CR.S 34-1-201(3) <br />A Other -anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional ge logist ?j <br />Contact / Company L2i ?( yt ?GQra /ii?,Ir?L <br />Address 1,`91 (2, & sx ,1,91 <br />City, State & Zip U em?rQ 60 <br />?G <br />Phone 7/ !l/ g- ,9 !/O,!V,?_ Fax 7/ ?- r<jp ??Sy <br />Print Name: / /iD?GifC V42^/011_, <br />Signature: <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, []Zone 12 or []Zone 13. <br />Easting Northing <br /># of Monitoring Hole(s to be constructed: <br />Estimated Depth O Ft., Aquifer <br />Purpose of Monitoring Hole(s) 1 ?0.?I i 021,?4 A/?E2 <br />Anticipated Date of Construction: <br />Date Notice Submitted: L2 o/"'xo <br />(Must be at least 3 days 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 htta:iinw?+.water.ctate 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 needed)