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GWS-51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />08/2008 Please type or print legibly in black or blue ink <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO-80203 <br />PHONE: 303-866-3581---FAX: 303-866-3589 <br />Well Owner's Name, Address & Phone 66 Dt• 1/?plp A11,11-1-4 (,p Location: y, SC ?, Section /7 <br />,r? <br />1 4QX Z91?, 1: Gi 1? 2C,-2 <br />(?o r?6 0 Township ??N (RS. Range k ?E,®W, (? T=PM <br />Landowner's Name / <br />?? if y 1-0 el (-0 County eye <br />Please check one and complete as indicated including contact info: Subdivision, Lot, Bik, Fig (as applicable) J? <br />? Water Well Driller Licensed in Colorado - Lic. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist per CRS 34-1-201(3) <br />CZ Other -anyone directly employed by or under the supervision of a licensed driller, <br />fegistered professional engineer or professional geol ist <br />Contact / Company z //r,C????/'?O.yj ?t ca, <br />Address 1- ,12, <br />City, State &^7Zi/p9V/G'-rng ro ?-7c?oAQ y <br />Phone // - ?ep_ ! Q `f ? Fax /19 " 6,o /9-O'.Z 5-1 <br />Print Name: x'14 "ex Z14 I-vo 1_/1 <br />Signature: <br />Site/Property Address _%EGLcke 6,,?-.V771 2e_110 <br />GPS Location in UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />the distance units, []Zone 12 or []Zone 13. <br />Easting Northing <br />ft of Monitoring Hole(s) to be constructed: <br />Estimated Depth 79WL, Aquifer <br />Purpose of Monitoring Hole(s) <br />7 <br />T??,v.;?yc,Ern /1a,?tii: o?E'iivu ?.?,•?? <br />Anticipated Date of Construction: //- /"--/ O <br />Date Notice Submitted: (/ -62(?-1Q <br />(Must be at least 3 days prior to construction) <br />`' - ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />- MH PROCESSED BY <br />DIV. WD _ BAS MD DATE ACKNOWLEDGED <br />CONDITIONS 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 of monitoring & observation hole(s). <br />2) Construction of the hole(s) 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 unless prior written approval is obtained from the State Engineer. Water diverted during testing <br />shall not be used for beneficiau purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying with all rules and <br />regulations pertaining to the discharge of fluids produced during testing. <br />3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum construction standards must be met or a variance <br />obtained. Standard permit application and work report forms are found on the DWR website at litto://w w?y.water.state co u.. Well <br />Construction and Test Reports (GWS-31) must be completed for each hole drilled. The licensed contractor or authorized individual must <br />submit the completed forms to this office within 60 days of monitoring hole completion. <br />4) Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment <br />Report (form GWS-9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's <br />structure name, and owner's name and address must be provided on all well permit application(s), well 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 remediation (recovery) <br />or as a permanent dewatering system, if constructed in accordance with the Water Well Construction Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" 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 DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />(Use above space for labels or additional conditions as needed)