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12-10-10 07:15 FROM-Colo Div of Water Resources +3038663589 T-508 P.003/008 F-572 <br />cw"I NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />CMOs Please type or print legibly in black or blue Ink 0 oii <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 621-DENVER-CO-80203 JO <br />PHONE., 3y0ME-3581-FAX: 303.886-2889 / <br />Well Owner's Name, Add 8, Phone a« Via0" / /'Ime (a Location; A -fW +/,, Section <br />e a & 9/ eea ervQ ng ea-e-612 Township IrON ($'S, Range jkt_ [:IEXTW, 6 7% <br />Landowner's Name c il? C/ G,p 171N re- County "'C'"?41f_ <br />Please check one and complete as Indicated Including contact into: Subdivision, Lot, Blk. Fig (as applicable) - <br />Q Water Well Driller Licensed in Colorado - Uc. No. <br />? Prolaselonal Engineer Registered In Colorado - Reg. No. <br />Professlonal Geologist per CRS 34-1-201(3) <br />Other -anyone dire* employed by or under the supervision of a fbonmW driller, <br />registered proressloval enggbrear or?pro onai 8a oglatf,/ <br />Contact / Company / 41-0-2 ICC'iN d,04 <br />Address A 0. 4 ac 19/ _ <br />City, State A Zip 1/i C. Q. ra C ?o P 61V <br />Phone Pax <br />Print Name: <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, OZone 12 or ]Zone 13. <br />Easting Northing <br /># of Monitoring Holes to be constructed: <br />Estimated Depth Wt., Aquifer <br />Purpose of Monitoring Hole(s) ?e,?! 7-41Zj! A/ <br />Anticipated Date of Construction: ?Q?' <br />Date Notice SubMitted: /a- 07-z <br />(Must be at least 3 days prior to conswalion) <br />f 'ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />q q J 2°I FOR OFFICE USE ONLY <br />- MH PROCE98ED BY <br />Div, y WD BAs MD DATE ACKNowLEDt3ED t2 - w to <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 A observation hole(s). <br />2) Construction of the hole(s) must be completed within RD days of the date notice was given to the State Engineer. Testing and/or <br />pumping shall not eucaad al totall of 200 hours unless prior written approval is obtained from the State Englntaer. Water diverted during testing <br />shell be used for bene6dal purposes. The owner of the hoWs) is responsible for obtaining permll(s) and complying with all rules and <br />regulations pertaining to the discharge of Gulds producQd during testing, <br />3) Ail work must comply with the Water Wall Construction Rules, 2 CCR 402.1 Mlrimum constnxAlm standards must be met or a variance <br />obtained. Slandard permit application and work report forms are fiound on the DWR wabelts at httb;/nswK.watar gtpte xo u•. Well <br />Construction and Test Reports (GWS-31) must be oomplated for each hole drilled. The licensed contractor or authorized Individual must <br />submit the compieted forms to We office within 60 days or monitoring hole completion. <br />4) Uh Ms 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 $ seating. The above MH acknowledgement number, owner's <br />structure name, and owner's name and address must be provided on all well permit application(e), well construction and abandonment reports, <br />B) The owner of the hale(s) shall maintain records of water quaLEty tasting and submit this data to the State Engineer upon request. <br />6) A MONITORING HOLE CANNOT Gil CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remacliation (recovery) <br />or as a permanent dawatering system, if constructed In accordance with the Water Well Construction Rules and policies of tho State <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE %MTHIN 98 DAYS, PLEASE WRITE, "NO HOLES CONMUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE. WITH THE FILE NUMGER AND FAX THE COPY TO THE DIV1910N OF WATER RESOURCES, <br />THIS ACKNOWLEDGEMENT OF NOTICE-DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />¦psce for Iabele or additional conditions as