2011-01-20_HYDROLOGY - M1980244

• Permit No: M1980244
• IBM Index Class Name: HYDROLOGY
• Doc Date: 1/20/2011
• Doc Name: NOI to Construct Monitoring Wells
• From: CC&V
• To: DWR
• Permit Index Doc Type: Hydrology Report
• Email Name: BMK
• Media Type: D
• Archive: No

12-10-16 07:16 FROM-Colo Div of Water Resources [phone] T-508 P.005/008 F-572
owes, NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
e9rzo011 Please We or print legibly in black or blue Ink O S4
COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203
PHONE: [phone]-FAX: [phone]
Well Owners Name, ?A? ddlm A Phena efC,f VPHta ll eLw(a Loo4on' Y '%, SecOon
/. Q, Qoe !:rnpp. C-0 ?De?bO_ Township _ACON W. Range LOE)®W, (o 77M
Landowner's Name CG j- IV 4 (D?.?4 ?lN(I?z CO county f ? ?
3ubdiWsion, Lot, Bik, F1g (as applicable)
Please check one and complete as Indicated Including contact Info:
Water Well Driller Lioensex! In Colorado - Uc. No,
? Professional Engineer Registered In Colorado - Reg. No.
? Professional Geologist per CRS 34-1-201(3)
Other -anyone directly employed by or under the supanAsion of a licensed driller,
glstered pr"slomi enpfnaer or professional g9loglst ti
Contact / Company
Address ler z
City, State A Zip
Phone 7/9-1-1
Fax
SIWPraperty Address
GPS Location In UTM format (optional):
Set GPS um'l to true north, datum NAD03, and use melem for
the distance units. ?Zone 12 or prone 13,
Easting Northing
0 of Monitoring Holes to be constructed;
Estimated Depth :? 0 Ft.. Aquifer
Purpose of Monitoring Hole(s) /"la,? 7-af.*?4 czt:-
Anticipated Data of Construction: / °?' -?
Print Name:
Signature: pate Notice Submitted; /2- 0 /-l
(Must be at lea-it 3 days prior to construction)
011 ACKN0IN1E GEMENT FROM STATE ENGINEER'S OFFICE
FOR OFr+ICE USE ONLY
- MH PRocEssm By
Dlv. 7,- WD 1 Z- SAS MD DATE ACKNOWLEDGED 2 'l0- l t7
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMNT SHALL BE AVAILABLE AT THE DRILLING SRE.
1) Notice, was provided to the Slate Engineer at (east 3 days prior to construction of monitoring 8, observation hole(s).
2) Construction of the hote(s) must be completed ,h tln 90 days of the date notice was given to the State Engineer. Tearing and/or
pumping chef not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing
shell n t be used for treneT+olai purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying wlth all rules and
reguleMons pertaining to the discharge of fluids produced during testing,
3) All work must comply with the Water Well Construction Rules, 2 CCR 402.2. Minimum construction standards must be met or a variance
obtained. Standard permit appicetlon and work report forma are found an the DWR webette at hNo:?hryew,watorstatc co.nr. Wail
Construction and Test Reports (OWS-31) must be completed for each hole drilled. The licensed contractor or authorized individual must
submit the oompleled forms to this office within 60 days or monitoring hole completion.
4) Unless a well permit Is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment
Report (form GWS-9) must tie submitted within 60 days of plugging & sealing. The above MH aoknowledgemem number, owner's
struotum name, and owners name and address must be provided on all well permit applioatlon(s), well construction and abandonment reports.
S) The owner orthe hotels) shall maintain records of waiter quairty testing and submit this data to the State Engineer upon request.
6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediatlon (recovery)
or as a permanent dewatering syslom, N constructed In accordance with the Water Well Constriction Rules and policies of the Snare
Engineer.
71 1F BOLES WILL NOT 139 CONSTRUCTED UNDER THIS NOTICE WITHIN Oct DAYS, PLEASE WRITE, "NO HOL28 CONSTRUCTED- ON A
COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUM$LR AND FAX T14E COPY TO THE DIVISION OF WATER RESOURCES.
THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED.
(Use ebova speoe for labels or additional condlitons as