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X12-10-10 07:18 FROM-Colo Div of Water Resources +3038663589 T-508 P.008/008 F-572 <br />aws-et NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />carioca Please type or print legibly In black or blue ink 0 .69 '8// -- f-? <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMM ST-RM 821-DENVER-00-80203 <br />PHONE: 303-866-3561-FAX; 303.6684569 J-! <br />Well Owner's Name, pAddres & Phone CG1t V?dc 0 / ,?/.?e CQ Lowtion: Section _"rw. C4 f?fh/?"?? Township j4CEIN US, Range ¦E,?W, "" PM <br />Landowner's Name C? w/. ?Q County _ _2,Gt'12 <br />Piastre check one and complete as Indicated including confect info, Subdivision, Lot, Bilk, Fig (as applicable) <br />? Water Well Driller Licensed In Colorado - Lie. No. Site/Propelty Aoidross <br />? Professional Engineer Registered in Colorado - Reg, No. <br />Q Pmfaselortei fle011091e1. per CRS 341.201(3) GPS Location in UTM format (optionan: <br />Set GPS unit to true north, datum NAD83, and use meters for <br />Other -anyone dlreptty employed by or under ire superytetan of a licensed drtler, the distance units. Mone 12 or []Zone 13. <br />registered profeaslonal engineer or pro atonal ae ogtst'/i Easting Northing <br />Contact / Company i i+R??J GI?P 4Deo i /„? r D *of Monitoring Holes to be constructed. <br />Address 9 Estimated Depth ?Ft, Aquifer <br />city, state & Zip GTsA Cie 4?o o Purpose of Monitoring Hole(s) 709/Z A4 <br />c'lc_ <br />Phone ? g - Q16^ yQ. yr Fax -L?Q?r t? ?5^ <br />Print Nama; Anticipated Date of Construction: 11-.113-10 <br />Signature' Date Notice Submitted: <br />(Must beet last 3 days prior to conslructlon) <br />WKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />'f7 FOR OFFICE USE ONLY <br />q - MH PROCESSED BY 6 <br />Div. [r WD I Zi SA8 MD DATE ACKNOWLEDGM -l0 -( 0 <br />CONDI110NS 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 or monitoring & observation hole(s). <br />2) Construction of the hotels) must be completed within 90 days of the date notice was given to the State Engineer. Testing and/or <br />pumping shall not exceed a total of 200 hours uniess prior written approval is obtained from tits State Engineer. Water diverted during testing <br />shall not be used for beneficial purposes. The owner of the hole(s) Is responsible ror ebtalning permit(s) and complying with all rules and <br />rMulatlone pertaining to the discharge of fluids pmduoed during iosting. <br />3) All work must comply with the Water Well Construction Rules, 2 CCR 402,2, Kftimum construction standards must be met or a variance <br />obtained. Standard permit application and work report forms ere found on the DWR web6Re at but,; m7<N,wstcr.Rtatc.ce.wr Well <br />Construction and Tact Reports (GINS-31) must be completed for each hole drilled. The licensed contractor or authorized individual must <br />submit the completed tufts to this ofAce within 60 days of monitoring hole completion. <br />4) lUnless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment <br />Report (form f3WS-9) must be submitted within 80 days of plugg)ng & sealing. The above MH acknowiedgement number, owneea <br />structure ,tame, and owner's name and address must be provided an all wall permit application(s), wall construction and abandonment reports. <br />5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request. <br />6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remedletfon (recovery) <br />or as a permanent dawatering system, N constructed in accordance with the Water Well Construetlon Rules and policies of the State <br />Eraglt?er. <br />7) IF HOLI5S WILL 140T BE CONSTRUCTED UNDER THIS NOTICE WITHIN 00 OAVS, PLEASE WPJT9, "PIG HOLES CON9TRt1CTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOSS NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />above space for labels or additional eonditlons a$ needed)