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12-10-10 07:17 FROM-Colo Div of Water Resources +3038663589 T-508 P.006/008 F-572 <br />awa-51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Damao Please type or print legibly In black or blue Ink o m 46// -119 <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821 -DENVER-CO-80203 <br />/ PHONF- 3y03-866-35581-FAX: 303-6663569 <br />wall Owner's Name, Addess & Phone lfeo Y 4PH,i0 //,?/I1q `d Location: Section - <br />?Qdo "6 Township jrQN I$S. Range kLME,EW, r'`PM <br />Landowner's Name I 4LIP&J ZZA-wllw rD County _-- ?t"7•ca'? <br />Please chock one and complete as Indicated including contact Into; Subdivision, Lot, Blk, Fig (as appilosble) <br />C3 Water Well Driller Llcenced In Colorado - Llo. No. <br />? Professional Engineer Registered In Colorado - Reg. No. <br />C] Professional Qeologist per CRS 341-201(3) <br />Other -anyone dheoey wnployod by or under the supervision of a licensed driller. <br />registered professional anollnneer orproofeselormi g (oplst <br />Contact / Company Zj& i9 C ?fi ??,n / / ??,1??? <br />Address 12 ,& &,..,1GqL.. -- <br />City, State & Zip GTMJ.. ra ?O <br />Sits/Property Address <br />GPS Location In UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />the distance units, I]Zons 12 or i]Zone 13. <br />Easting Northing <br /># of Monitoring Holes to be constructed: <br />Estimated Depth Ft., Aquifer <br />Purpose of Monitoring Hole(s) /&AeV 7-094.1^4 W <br />Phone g- 6?-y0, Fax <br />Print Name: Anticipated Dote of Construction: /e2. <br />r?O?? <br />Signature; Date Notice Submitted: /2- 0? ?? <br />(Must be at beat 3 days prior to construction) <br />ACKNOWLEDGEMENT FROM STATE ENGINEEFVS OFFICE <br />FOR OIrmes USE ONLY <br />- MH PROCESSED BY <br />Div. _, WD 7i BAs MD DATE ACI(NOWLEDGED f If - l0 - f 0 <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE <br />1) Notice was provided to the State Engineer at least 3 days prior to construction of monitaring & observation hole(s). <br />2) Construction of the hole($) must be completed wtthln 9R davs of the date notice was glean to the State Engineer. Testing and/or <br />pumping shall not exceed a Dotal of 200 hours unless prior written approval is obtained Nam the State F.rtgineer, Water diverted during testing <br />shall not be used for benefloW purposes. The owner of the hole(s) Is responsible for obtaining pemtH(s) end complying with all ales and <br />mgulatlons pertaining to the discharge of fluids produoed during testing. <br />3) All work must comply with the Water We!! Construction Rules, 2 CCR 402.2. Minimum construction standards must be met or a variance <br />obtained. Standard permit applloetbn and work report forma are found on the DWR website at nou .1rg tnr.ctateM11.113 . Well <br />Construction and Teat Repots (GWS-31) must be completed for each hole drilled. The Ooensed oontractor or authorized individual must <br />submit the completed forms to this anise within W days of monitoring hole completion. <br />4) Unless a wall permit is obtained, the hole(s) must be plugged and sealed within one (1) year attar constructlon. An Abandonment <br />deport (form GWt3-s) must be submitted within 60 days of plugging & seallrg. The above MH acknovdedaement number, owner's <br />structure name, end owners name and address must be provided an all wall permit application(s), well contortion and abandonment reports. <br />b) The owner of the hotels) shall maintain records of water quality testing and submit this data to the State Engineer upon request. <br />6) A MONITORING HOLE CANNOT BE COWERTED TO A PRODUCTION WATRR WELL, except for purposes of ramediation (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 ACKNOWLEDOF,A NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />THIS ACKNOWLEDGRIVIENT OF NOTICI5 DOES NOT INDICATE THAT WELL PERMIT(S) CAN 00 APPROVED, <br />space for labels or additional oondltiom w