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e , 10/14/2010 06:34 7196893254 CCVGMC PAGE 02103 jf,?f;; NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) Carioca Please type or print legibly In Waok or blue ink /vIP`?? Q?S COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 PHONE: 303.86&3681--FAX: 30HW4589 Wel Owner's Name, Address aft Phone Co ?? 4?ezl''? ?0 Qa /9/ Landowner's Name Cc Please check one and complete as indicated including contact info: ? Water Weil Driller Ucansed in Colorado - Uc. No. ? Professional Engineer Registered In Colorado - Reg. No. ? Professional Geologist per CRS 34-1.201(3) Pff Other -anyone direct) employed by or under the supervision of a licensed driller, registered proiesslonsl vVinser or profe??ssi?sional geologist Contact ICompany_AARkX 11.4ae ????G?Qao?l??wtfra Address ,.00-0&r. wo City, state a Zip VjG, Phone D er Fax 7/9 - Print Name: Signature: Location: '/, '/,, Section Township L7oN MS. Range ?[IE OW,??PM County , / a r Subdivision, Lot, elk, FIg?z'piicabie) Site/Property Address E CO GPS Location In UTM format (optional): Set OPS unit to INS north, datum NAD83, and use meters for the distance units, [tone 12 or [Zone 13. Easting Northing # of Monitoring Hob(s) to be constructed: E3timated Depth 2,fl2_FL, Aquifer Pu a of Monitoring 11,101e(s) 7a 'd- ,t 0 A_ -r12AA0,o e% 1.0% "-7V4 "OV Anticipated Date of Construction: Date Notice Submitted: ? s f = (Must be at less/ 3 days prior to construction) ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE ! c FOR OFFICE USE ONLY (41 q 61 - MH PROCESSED BY Div. S, WD 7i PAS MD DATE AcKNowl-EDGED CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHAD, BE AVAILABLE AT THE DRILLING GRE. 1) Notice was provided to the State Engineer at least 3 days prior to conduction of monitoring & observation hole(s). 2) Construction of the hole(s) must be completed within 9000 dm of the date notice was given to the State Engineer. Testing and/or pumping shall not exoeed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing shall not be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining pemtit(s) and complying with all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum oonstuotlon standards must be met or a variance obtained. Standard permit application and work report forms are found on the DWR website at 11tt,?:INrww+walcrststk.cmus, Well Construction and Test Reports (GWS31) must be completed for each We drilled. The licensed contractor or authorized individual must submit the completed forms to this office within 60 days of monitoring hole completion. 4) Unless a well permit is obtained, the holo(s) must be plugged and scaled within one (1) year after construction, An Abandonment Report (forth GWS3) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owners structure name, and owner's name and address must be provided on all well permit application(s), well constructtkxr and abandonment reports. 5) The owner of the hole(s) shall maintain records of water quality testing and submit this date to the State Engineer upon request 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of rsmodiation (recovery) or as a permanent dewatming system, If constructed In accordance with the Water Well Construction Rules and poQelas of the Stab Engineer. 77 IF HOLES ML NOT dE CONSTRUCTED UNDER TH16 NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A COPY OP THE ACKNOWLEDGED NOTICE WITH THE PILE NUMBER AND FAX THE COPY TO THE DNISION OF WATER RESOURCES. THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. - (Use above space for labels or additional conditions na needed)