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10/14/2010 06:34 7196693254 CCVGMC PAGE 03/03 J?E_CI::!U?;. ew"l NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S); ; owme Please type or print legibly In black or blue ink COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 " PHONE; 303-866-3561-FAX' 303.866-3589 Well Owner's Name, Address Phone CG G-dL? i . (D LOeation:'? '- Y. „?w Y., Section TOwnshipl.5- ?N ? Range ? ?E ;gW, (.)ArM Landowner's Name CC-36 V "" %1. *0 CD County T aw Subdivision, Lot, Blk, Flg (as a Igbte) Please check one and complete as Indicated Including contact Into. /± .. ? Water Well Driller Licensed in Colorado - Lis No, She/Property Address _ LL6k C/?y p ? Professional Engineer Registered in Colorado - Reg. No. ? Professional Geologist per CRS 341.201(3) GPS Location in UTM format (optional): Set OPS unit to true north, datum NAD83, and use metera for ,9 Other -anyone directly empnoyod by or under the supervision of a Ibensed driller, the dietance units, ]Zone 12 or ?Zone 13. rapisterod professlorml en r ororal geolog' Easting Northing Contact /Cart 7w wr AW g Monitoring Hole(s) to be constructed: Address r / ?bJ? l1 L Estimated Depth 7M Ft., Aquifer City, State & Zip `- < C19 evel 0 Purpose of Monitoring Nola(&) 7& Ait- eAy Phone - - y6 f Fax - 5221 T Aiwa ?LFFP d?i?.e%?l ??ELL /?f Anticipated Date of Construction: Print Name: / / ? ? Signature. Date Notice Submitted. (Must be at least 3 days prior to consinxUon) ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE f q Y 6 FOR OFFICE USE ONLY - MH PROCESSED BY Div. 2- WD ?Z SAS MD DATE Acmowmow to CONDITIONS OF' MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. 1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hob(s). 2) Construction of the hole(s) must be completed within 90 es of the data notice was given to the State Engineer. Testing and/or pumping shall not exceed a total of 200 hours unless prior w Main approval Is obtained from the State Engineer. Water diverted during testing shall not be used for bsnef W purposes. The owner of the hole(s) is responsible for obtaining parmit(s) and complying with all rules and rogutailons pertaining to the discharge of fluids produced during tasting. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402.2. Wnimimm won standards must be mart or a valance obtained. Standard permit application and work report forms are found on the DW R website at httr,e/1ww-w.w^ taetcr.eh,co,_. Well Construction and Test Reports (OM-31) must be completed for each hole drilled, The licensed contractor or authorized indtuldual must submit the completed forms to this ofics within 60 days of monitoring hole completion. 4) Unless a wall pormit is obtained, the hole(s) must be plugged and sealed within one (1) year alter construction. An Abandonment Report (form OWS41) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, ownees structure name, and owner's name and address must be provided on all well permit appiioation(s), well construction and abandonment reports, 5) The owner of the hole(s) shall maintain records of water quality 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 proposes of remodiation (recovery) or as a permanent dewatering system, If constructed in accordance with the Water Wail Construction Rules and policies of the State Engineer. 7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, 'NO HOLES CONSTRUCTED" ON A COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURGES, THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. (We above space for labels or additional conditions as nesdoc