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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 _ /'/0 1,/ _ (!) jov <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 <br />PHONE: 303-866-3581---FAX: 303-866-3589 <br />Well Owner's Name, Address & Phone CC f y4401_,0 //-11.14 6D <br />look /9';P?? CO oclvh y <br />Landowner's Name CC-V( V4'0 I-0 //1,V1JV4 (O <br />Please check one and complete as indicated including contact info: <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 />,Lry Other -anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologis <br />A,e <br />Contact / Compann? //- -?- /V'P10,?/ t?G dl/?nQL?! //Ni.+2 ?0 <br />Address i ? l?ln)G ?9? <br />City, State & Zip / Ill e- e. Co eve& 0 <br />Phone ?0W Fax 717 -4 Q 7 '..?_ y <br />Print Name: 11'114& t114^101?/ <br />Signature: <br />Location; IVNt' y, /V y,, Section / <br />Township/,S- ?NWRange 6 9 [3E;VW, 66*m <br />County TELLER <br />Subdivision, Lot, Blk, Fig (as applicable) <br />Site/Property Address ??--`` <br />_TELGE,Q C.?'? /e <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 ,EO Ft., Aquifer <br />Purpose of Monitoring Hole(s) 7 AE j5r1PaV -AW, <br />Anticipated Date of Construction: <br />Date Notice Submitted: //- <br />(Must <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 Itttp:/hvtti??.waterstate 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)