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12-10411 07:15 FROM--Colo Div of Water Resources +3038663589 T-508 P.004/008 F-572 <br />crwa.st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />moos Please type or print legibly In black or blua Ink o .64 ,811 _, 7 <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RIM 821 -DENVER-CO-90203 <br />PHONE: 303-868-3661-FAX: 303-6S"689 <br />r's Name, Add & one ifent yC on o 17, " Location: '/,, Section <br />Well Ownee r <br />s ?? G 'f?Q Township -SbN MS. Range 0 DE.OW, ,,' " I'M <br />Landowner's Name C t o / //IV County zV±t R - <br />Subdivision. Lot, Sik. Fig (as applicable) <br />Please check ono and complete as Indicated Including contact Info: <br />0 Water Wall Driller Licensed In Colorado - Llo. No. <br />? Professional Engineer Registered In Colorado - Reg. No. <br />? Professional Geologist per CRS 34-1-201(3) <br />Other -anyone oirectly employed by or tinder the 3upermlon of a Iloenaed drllter, <br />registered profeasfonal onglMer or projeselonal geyoglst - ti <br />Contact/ Company (1A ? I.F.o ?(l.(T or CA F/1.0 , 'r <br />Address c J <br />City, state & Zip 1/1 C,7 d Ca eo t? <br />Phone 7J 9 - Ml- ?a f/g Fax 71,9- <br />Slte/Propeny Address <br />GPS Location in UTM format (optional): <br />Sol GPS unit to true north, datum NADS3, and use metert for <br />the distance units, ©Zone 12 or [3Zone 13. <br />East)ng Northing <br /># of Monitoring Holes to be constructed: <br />Estimated Depth < Ft., Aquifer <br />Purpose of Monitoring Hole(s) A f7 ) T02/n/4 efZL <br />Anticipated Date of Cortstructlon: Ax <br />Print Name: <br />Signature: Date Notice Submitted: <br />(Must be at least 3 days prior to construction) <br />ACKNOW LED EMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />t? - MH PROCESSED BY - ?? <br />Div. Z WD 1 Z SAS MD DATE ACiwowLEDOED /L-to - f o <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 BIO days of the date notice was ghron to the State Enginew. Testing and/or <br />pumping shell not exceed a total of 200 hour unless prior written approval is obtained from the State Engineer. Water diverted during testing <br />WWI n s be used for bmneficial purposes. The owner of the hole(s) is responsible for obtaining permh(s) and complying with 211 rules and <br />regulations pettalning to the discharge of fluids produced during testing. <br />9) All work must comply with the Water Well Construction Rules, 2 CCR 402.2. Minimum construction standards must be met or It variance <br />obtained. Standard permit application and work report fom16 are found on the DWR webslte at htterl/wtitiv.water.atme cu.nrc. Well <br />Construction and Test Reports (GWS-31) must be completed for each hole drilled. The licensed conlraclor or authorized individual must <br />submit the completed forms to this office wlIhln 60 days of monitoring hole oompletion. <br />4) Unless a wall permit Is obtained, the hole(s) must be plugged and scaled within one (1) year after construction. An Abandonment <br />Report (form GWU) must be submitted within 60 days of plugging & seeding. The above MK aciutowledgement number, owner's <br />structure name, and owner's name and address must be provided on all wel patriot application(s), well oonstruadon and abandonment reports. <br />S) The owner of the hole(s) shall maintain records of water quality testing and submit this date to the State Engineer upon request. <br />6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of rom idiation (recovery) <br />or as a permanent dewatering system, N constructed in aecordanw with the Water Well Construction Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT BE CCWS3RUCTED UNDER THIS NOTICE WITHIN 913 DAYS, PLEASE WRITE, "NO MOLES CONSTRUCTED" ON A <br />COPY OP THE ACKNOVAJMED N071CE WITH THE FILE NUMBER AND FAR THE COPY TO THE DIVISION OF WATER RESOURCES. <br />THIS ACICN0WLBDG6MBNT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED, <br />space tar cabers or eatimonor conmuons as