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2011-01-20_HYDROLOGY - M1980244
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2011-01-20_HYDROLOGY - M1980244
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Entry Properties
Last modified
8/24/2016 4:29:12 PM
Creation date
1/26/2011 7:34:21 AM
Metadata
Fields
Template:
DRMS Permit Index
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
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112-10-10 07:17 FROM-Colo Div of Water Resources +3038663589 T-508 P.007/008 F-572 <br />owsah NOTICE OF INTENT TO CONSTRUCT MONITORING HOL <br />E(S) <br />. <br />ceases Please type or print legibly In black or blue Ink Q jY4 ?? U? ?, <br />?T <br />COLORADO DMSION OF WATER RESOURCESA313 SHFMAN ST-RM 821-DENVER-CO-80203 <br />P <br />HONE;303.889-3681-FAX: 303.866.3589 <br />PH <br />Well Owner's Name, Addreg & Phone 661t via e??o /7j ejnj Ca J <br />Location: lVkl Y. /V_ X, Section <br />Q, OZ Z& c mw CO Township45:nN I da, Range C1E.0W, a 7'0PM <br />Landowner's Name p County ?1.?•t /R <br />Please check one and complete as Indicated including contact Info: subdivision, Lot, Blk, Fig (as applicable) <br />? Water Well Driller Lloensed In Colorado - Lic. No. 31te/Property Address <br />? Professional Engineer Reglatered in Colorado - Reg, No. <br />Professional Geologist per CRS 34-1-201(3) OPS Location In UTM format (optional): <br /> <br />Other -anyone directly employed by or under the supervision of a licensed drlilor, <br />regletered profeemon d engineer or p alone! 9 logisl Set GPS unit to true north, datum NAD63, and use meters rvr <br />the distance units, QZone 12 or [3Zone 13, <br />?y <br />Contact I Compsmy l_ fQ?E.11AMZ?/ lee j?+%G QW 0/? tasting Northing <br />?p O p <br />Address / # of Monitoring Hola(s to be constructed: <br /> <br />city, state & Zip II e-i C ffo Estimated Depth Ft,, Aquifer <br />Purpose of Monitoring Holes) JTORrir/4 L??? <br />Phone 7/ Fax <br /> <br /> <br />Print Name: <br />ON <br />Anticipated Date of Constructlon: AX -/ 7"149 <br />Signature: Data Notice Submitted: ^ 0 <br /> (Must be ai least 3 days prior to construction) <br />/ ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />4175-7 FOR OFFICE USE ONLY <br />MH PROCESSRO BY <br />DN. ?- WD Z- SAS MD DaTia ACKNowLEDal;p tz ' (0 ` ( O <br />CONDITIONS OF MON11I`101UNG HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRrrMN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SrM. <br />1) Notice was provided to the State Engineer at least 3 days prior to construction of monitging & observation hob(s). <br />2) Construction of the hole(s) must be completed within 90 , of the date notice was given to the subs Engineer. Testing and/or <br />pumping shall not exceed a total of 200 hours unless prior wdttm approval is obtained from the State Engineer. Water diverted during testing <br />shall be used for bendtcal purposes. The owner of the hole(e) is responsible for obialning permh(s) and complying with all rules and <br />regulations pertaining to the disoharge of fluids produced during testing, <br />3) All work must comply with the Water Wail Construction Rules, 2 OCR 402-2, Wwomum construotion standards must be met or a var)snos <br />obtdiKd. Standard permit application and work report forms we found on the DWR website at httayrwKt. wr/tg utetc ce?oa. Well <br />Construction and Test Reports (GM(341) must be completed for each hole drilled, The licensed conaaMr or authorized individual must <br />submit the compieleci forms to this office wlthln W days of monitoring hole completion, <br />4) Unless a well permit Is obtalmed, the hole(s) must be plugged and sealed within ens (1) year after construction, An Abandonment <br />Report (form OWS.B) must be submitted within 00 days of plugging & sealing. The above pow acknowledgement number, owner's <br />atrustum name, and owner's name and address muss be provided on all well permit application(s), well oonstructton and abandonment reports. <br />5) The owner of the hole(s) shall maintain records of water quality tasting and submit (hie data to the Btato engineer upon request. <br />6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of rernediation (recovery) <br />at as a permanent dawatering system, If constructod in accordance with the Water Well Constnuclion Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 80 DAYS, PLEASE WRITE, "NO HODS CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION Or WATER RESOURCES, <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED, <br />apace for labels or addldonai conditlons as
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