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12-10-10 07:14 FROM-Colo Div of Water Resources +3038663589 T-508 P.001 F-572 <br />taws-61 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />ottr2ooe Please type or print legibly in black or blue Ink o s,A <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST•RM 8214DENVER-CO.80203 <br />PHONE. 3??03.866..3881--FAX 303$66-3689 `? <br />Wall Owner's Name, Addre9 & Phone C et Vtw 4G.a i / „y v?(a I-ovation: ?/, ?v' y,, Section <br />?a, QOk ?* 77,'Td"P CO AM60 Township jXEIN XS, Range jkL ?ERW, (/V'714rM <br />Landowner's Name _ C G yt 11,4P1,a /7".4- ^,z pCounty %? <br />Please check one and complete as Indicated including contact info: Subdivision, Lot, Slk, FI9 03 applicable) <br />? Water Well Driller Licensed In Colorado - Lic. No. <br />? Professional Engineer Registered In Colorado - Reg. No, <br />? Professional Geologist per CRS 34-1.201(3) <br />Other -anyono directly employed 4 or under the supeivision of a Ilconaed drIller, <br />Istmo Professional engineer or ?prormak"I ge Isl / <br />Contact l Company _(/+?? C[ r><1/? co der" <br />Address /" . C1, 4 PC 4 7 <br />City, State a Zip G771 O ?O cic7/ <br />Phone 719- 4014? Fax <br />Print Name; <br />Signature: <br />SitelProperty Address <br />GPS Location in UTM format (optional): <br />Sol GP8 unit to true north, datum NA083, and use meters for <br />the distance units, []Zone 12 or []Zone 13, <br />Easting Northing <br />0 of Monitoring Hola(s to be constructed; <br />Estimated Depth !? Ft., Aquifer <br />Purpose of Monitoring Hole(s) oN/T02/??4 ??'l?. <br />Anticipated Date of CcnstrucWn: 4e <br />Date Notice Submitted: 462 ^ 0 L62 <br />(Must be at (oast 3 days prior to construouon) <br />ACKNOWLEDGEMENT PROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH PROCESSED BY <br />Drv. Z WD !Z_ SAS MD DATE ACKNOWLEDGED 1 Z ' IO -1? <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHAW, 13E 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 wlthln 8 des, of the date notioe was given to the State Engineer. Testing and/or <br />pumping ft l 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 baneflolal purposes. The owner of the hole(s) Is responsible for obtaining permh(s) and calInpiyf ng with all rues 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. Mlnimum comtruation standards must be met or a varience <br />obtained. Standard pamA application and work report rorms are found on the DWR website at kan:r wrsor asaco.ns 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 forme to Ihis office within 60 days of monJtoring hole completion. <br />4) unless a wall permit Is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment <br />Report (form 1311118-9) must be submitted wlthln 60 days of piugging & sealing. The above MH aftowledgement number, owner's <br />structure name, and owner's name and address must be provided on all well permit appllcatlon(4 well construction and abandonment reports, <br />6) 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 ramediation (recovery) <br />or as a permanent dawatering system, if oonstructed In accordance with the Water Well Construction Rules and policies of the Stella <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN go DAYS, PLEASE WRITE, "NO HOLM CONSTRUCTED'1 ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WrrH 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 />above space for labels or eadlttonal condltlons se