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Ol-12-11 11:42 FROM-Colo Div of Water Resources +3038663589 T-572 P.001/002 F-830 <br />ev" NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />oanooa Please type Or prkrt legibly In black or blue ink <br />0/ ?//!dd'- 012. yQ /off <br />COLOPMO OIVLSION OF WATER RE8WRC65.1313 8H6RMAN ST.M 921-DEM//ER40.g = <br />PHONE; Mp8.8I38.3681--FAX: 303-M4689 <br />Well Corner's Name Address 8 Phone _C?/'or? ?co <br />Landowner's Nana ----..? _S?o //lw/li?J ?ati <br />Please chock one end oompteM as lndt MW Including contact hrfb: <br />? Water Well Driller Licensed in Colorado - Lto. No, <br />? final Engfnasr Registered In Colorado - ReEI. No. <br />? P10fessional C3800t Par CRS 34.12D1(3) <br />Other anyone dkwtly wnpftw <br />Bred profeubmai any r or pq <br />Contact/ Company .o <br />Addtass __,& <br />City, state a zip <br />Phone^6??- f/? y <br />Print Name: <br />Signature: <br />or waW ft WPavbton of a Imneod drlksr, <br />e'00, <br />Fax <br />Loaatloo: y ,? Y Section '?? <br />Townehlp ©N C?RanW QE <br />CCU* <br />SubdNSl011?F?lg (its jp?wble) <br />61tWmpo* Address ?fti? (Oww??w <br />GPS Location In UTM format (optional): <br />Sot QPS unit to hue no"ll, datum NAD83, and use meters for <br />the distance units, Mons 12 or OZone 13. <br />F.astkg Northing _ <br />S of MordtoHng Hole(s) to be riwu uoted: --_ <br />Esllmatsd Depth /DO Ft., Aqutter <br />AMP of Mormodng Hola(e) pL <br />Q1 <br />AntfolpspW pate of construction: A6:6CL111 <br />cote notice 81EbEnittad: ®/- /eI- // <br />(Must be st leapt 3 dayo Prior to eonetnmilon) <br />ACIKNOWLEDGI;MENT FROM STATE ENGINEERS OPFICE <br />6 C5 • 67 FOR 0F19CE USE ONLY <br />MH PROCUMBY <br />DIV. ?- WD I L BAB IVIo I -l2-G <br />DATE ACKWWLMX= <br />CONDITIONS of MO <br />1) <br />3) <br />4) <br />S) <br />6) <br />7) <br />1,011 O HOLE ACKNOWLEDGEMENT <br />A COPY OF TH>E tNRRTEN NOTICE OR Atpl <br />DEMENT SHALL BE AVAIlA"AT THQ DRILLING SITE. <br />NaU= was pnwklod to ow State &Wnwr at IaM a dells prior, to constnadton of mlwdforing & obsorvation hote(e). <br />offs() must be completed wtfhlq of the date MIN was ghran to the Sfata t lIghwer. Testing and/or <br />pumping shall not exceed s total of 2DD hours unless prior written approval Is obtained from qte State <br />Ah'An.4) be used for beneficial purposes The owner of the s) N respanslWe for obteirlfnp pe c Wotar diverted during testing <br />rVill0ns perfatrdng 10 the diactnafge offulds produced rmH(e) and complyhtg with all Was and <br />AR Work MW dlrbtp ??. <br />Comply Wh the Water Wei! Constr WM Raise, 2 CCR 41124 Minimum con8httdion standards must be met or a variance <br />obtained. Standard p9m* appbstion and warts report 0iarma am torrrrd on the DWR wabslle at h Well <br />Cons v*w. and Teat Reports (GWUI) must be • 101 <br />camptetad fvr each hots dr1118d. Tha 1(cerued cordraetor or autltoNzed in0dhrldual must <br />at"* the 0onlplstad fOMIS to arts 00108 within W days or rnW tt ft hole Completion. <br />t now a wad psmdt Is obtalnad, the 11010(8) must 110 plugged end sealed wItIM one (4) year alder corliswuctilion. An AbwWonrrmo <br />Report (form = &@) must be su6mtlf0d WOW So daya Of l4u111101ing A aaaft The above MH aolamwtedgema,t number, owners <br />structure name, end owners now and address lmret bo provided on Ali well permit 4110011100gon(0), well cmftwan and abandonment reports. <br />The owner of the hota(8) 811x1 matrlfatn now* of water quaflty too ft and submd of cis% to the Slate Engbtear upon request <br />A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except far purpose of mmsdlow (noovwo <br />or es a PennWmM dewatatfng system, If corlatrurasd In acconfance wrllh the Wafer Well won Rules end po8eles of fie Strut <br />Engineer. <br />IF HOLES WILL NOT BE COleiISTRUMM WVDRR THIS NOTICE; WITHgr 90 PAYS, PLEA 9G WRn'E, "NO HOLES CONSTRUCTED" ON A <br />COPY OF T"8 ACKyaWL1DQED NOTICE WIT" THII FILE NUMER AND PAX THE COPY TO THE DIVISION OF WATER REsOtRtces, <br />THIS ACKNOWLEDGEMENT OF NOTICE pOES NOT INDICATE THAT WELL PMIT(g) CAN BE APPRoVen. <br />space for labels or adddw-a wno[-ar e M