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12-10-10 07:14 FROM-Colo Div of Water Resources +3038663589 T-508 P-002/008 F-572 owe-511 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) . oerAos Please type or print legibly in black or blue ink O rR COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST•RM 821-DENVER-CO-89203 PHONE: 3??03-800-3SOI --FAX' 303.668-3588 Addres & Phone 6614 ?4 ?iO / / ?-, ,?4 a Luton: f? % ik 1/., Section / to Well Owner's Name, / /q ,Q Qa g/ e-rap 60 Township ?[]N ($S, Range jL QEXIN, ? TIC'PM Landowner's Name C C pt V 6' -C 4 / N Q County Please cheek one and complete as Indicated including contact Info: Subdivision, Lot, Bilk, Fig (as applicable) 0 Water Well Driller UcensQd In Colorado - Lic, No. ? Professional Engineer Registered in Colorado - Reg. No. © Professional Geologist per CRS 341-201(3) Bitter -anyone directly employed by or under the su parvlnlon of a licensed drAler. registered professional engineer or professional gegioglel. Contact t company 1-4--- Address / c !,. V City, Stare $,Zip GTrJ ??? Phone 7/ ?46-440 4ik Fox Print Name: Signature: Site/Property Address GP9 Location In UTM format (optional): Sal GPS unit to true north, datum NA083, and use metem for the distance units, ©Z,one 12 or [32one 13. Easting Northing # of Monltoring Holes to W constructed: - - Estimated Depth Pt,, Aquifer Purpose of Monitoring Hole(s) 27 n / O2L?l_! r- Anticipated Date of Construction: X2--/Z=/12 Date Notice Submitted: (Must be al least 3 days pflor to construction) ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE: USE ONLY ? S - MH PROCESSED BY Div. 2- WD j 2- BAS MIS DATE AcKNOwLEOCIED f0 CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAELABLE AT THE DRILLING SfM 1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). 2) Construction of the hole(s) must be completed within 9„0 eyg of the date notice was given to the State Engineer. Testlng and/or pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during tasting shat Qg( be used for beneficial purposes, The owner of the hole(s) Is responsible for obtaining permit(s) and complying with all rules and regulations pertaining to the discharge of fluids produced during WoUng. 3) All work must comply with the Water Well Construction Rubs, 2 CCR 4022, Minimum cwnsIrwaon standards must be met or a variance obt>,alned. Standard permit application and work report forms are found on the DWR webslte at Lttg:Nmc.vrv.wt?ter.state co,yt. Well Construction and Test Reports (GWS-39) must be completed for each hate drilled. The licensed contractor or authorized individual must submit the completed forms to this office within 80 days of monitoring hole completion. 4) Unless a well permit Is obtained, the hole(s) must be plugged and seated within one (1) year after construction. An Abandonment Report (form GWS-S) must be submitted enMIn 60 days of plugging 9 sealing. Thu above MH acknowledgement number, owner's structure name, and owner's dame and address must be provided on an well permit application(s), well construction and abandonment reports. 5) Tho owner of the hole(s) shall nmalntain records of water quality testing and submit this data to the State Engineer upon request. 61 A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WA'T'ER WELI, except for purposes of romediation (recovery) or as a permanent dowatering system, If constructed In accordance with the Water Well Construction Rules and policies of time State Engineer. 7) IF HOLES VALL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN eo PAYS, 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 PERMTTJS) CAN BE APPROVED, above space for labels or additional conditions as