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i <br />01-03-11 06:55 FROM-Colo Div of Water Resources +3038663589 T-547 P.001/001 F-731 <br />we-61 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oeacoa Please typa or Print le <br />glbly in black or bloc ink <br />COLORADO DMSION OF WATER RESOURCE&1313 SHERMAN ST•RM 821-DENVER41 M <br />,CO-W2 _ <br />PHONE 30"66-3581-FAX- 30346"M <br />10111 1 /1 9 <br />Well Owner's Name, Address & Phone +` <br />f'o 8 010*0 G O <br />Landowner's Name <br />_CZ pi /71010914f cy- <br />Please check one and complete as indicated InClWding contact Info: <br />? Water Well DrIller Licensed in Colorado - Lio. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist Per CRS 34-1-201(3) <br />Other -myone directly etnp?oWd by Or under the supervision of a IlCensed dribr, <br />nagWered profe"[Drial englt?eer ar proles tonal eearaglst <br />Contact I Company t'117 4 ? - <br />Address Airar 9? /?'?(L! <br />City, State a Zip <br />Phone UtJ::JVQ e Fax <br />M _ w <br />Print Name; <br />Signature: <br />LOcatlom' Y, Section /-A Z- <br />Township ZON;011, Range (]E WW, CoZ M <br />County ai 1, Ie <br />Subdivision, Lot, 131k, Fig (as app <br />Slta/PrOPerty Address On/ , <br />GPS LaCatlon In U IN format (optional): <br />Sol OPS unit to true north, datum NAD83, and use meters for <br />the distance units. QZone 12 or C)Zone 13. <br />Eseting Northing <br />H of Monitoring Hole(s) to be constructed: <br />Estlmato Depth _.A-Vat„ Aquifer <br />Purpose of Monitoring Hoists) <br />n/.t'Ddc r <br />Anticipated Date of Construction: <br />Date Notice Submitted: AL--? 1-14.1 <br />(Must ba e1 NMI 3 dive prior to ooralruotlonl <br />U[? q -mmuni-t:txsEMENTFROM STATE ENGINEER'S OFFICE <br />-F t S G s FOR OFFICE USE ONLY <br />MH PROCESSM BY <br />Div. L- WD Z BAS MO <br />DATE ACKNOWLEDGED <br />CONDITIONS OF AAOWPORI <br />1) <br />2) <br />3) <br />4) <br />5) <br />6) <br />7) <br />A COPY OF THE NG HOLE ACKNOWLEDGEMENT <br />WRITTEN N071CE OR ACKNt3MEp"1111111ENT SHALL BE AVAILABLE AT THE DRILLING ST6. <br />Notice was proAded to the State Engineer at Mao 3 days Data to ease iructlan of monitoring $ observation hale(s). <br />Constructbn of the hale(s) must be carr?plebad yritttim ?0 of ttta data notice tares ghren to the State Engineer. Testing andlor <br />Humping shall not exceed a totol of 200 hours unless prior written approval is obtained from the State Engine ?,pQ( be used for bereft l pulposea The Owner of the hole(s) is responsible <br /> for obtaining permil(s) and e=m star diverted during testing <br />regulations PwWtning tc the discharge of fluids produced during teft. PI?nB wrtl+ alt rules and <br />All work must camMy with the Water Well Corptruraion Rules, 2 CCR 4WZ Minimum construction standards must be met or a variance <br />obtained. Standard POMII -Wicallon and work nit ft "s era found an the DWR wotx to al hnar,_?1ww ?,VA ?aratc -a cs. Well <br />Construction and T4st Reports (GWS41) must be completed for each hale drilled. The licensed contractor or authorized Individual must <br />submit the completed forma to this office within 80 days of monitoring hate completton. <br />Unless a crap putt Is obtalned, tine hole(s) must be plugged and sealed within ono 1 <br />Report (form G" must be sttbrrtitted within 8o da ? () year a oortstrtratlan. An Abandonment <br />structure Helms, and owna,'s name and address must be of plugging & sealtmp, The above MK acknowledgement number, owners <br />The owner n a h provided an all well MM appllCallon(s), wag construction and abandonment reports, <br />of the Olets) shall mtabtte)n records of water quality testing and submit this data to the Stets Engineer upon request. <br />A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WECt <br />or as a permanert dewatering 4"tn, If constructed In accordance with the .a t Con for <br />struction purposes Rules of and d policies es (recovery) <br />Engineer. Weber Well Con of the State <br />IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS. PLEASE WRITE, "NO HOLES CO " ON A <br />COPY OF THE ACKNOWLEDGED NOTmE WITH THF. FILE NUMBER AND FAX THE COPY TO THE aNISiOH OF WATER REBpUMES, <br />TM ACKMLEDGC-NENT OF NOTICE DOES NOT INDICATE THAT WELL 111011WIT(S) CAN BE APPROVED. <br />4131+08 for label-7r additttxtal oondloons me