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11-09-10 <br />owsbl <br />oerm <br />08:06 FROM-Colo Div of Water Resources +3038663589 T-409 P.001/002 F-303 <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please type or print legibly in black or blue ink -11,d1,1 - 0 -7 <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM B21-DENVER-CO.80203 <br />PHONE 303-888-3581-FAX; 303.866.MN <br />Well Owner's Name, Address & Phone NCO, <br />.. 0? ox ?9'/,,..CLcTD?E. Cf t 01?,?iL <br />Landowner's Name GG?r/ G Dl?? J?J?/J?t/d t?0. <br />Please check one and complete as Indicated Including contact Info: <br />? Water Wail Driller Licensed In Colorado - Uc. No. <br />? Professional Engineer Registered in Colorado - Reg. No. <br />? Professional Geologist per CRS 34-1.,201(3) <br />XOther -anyone directly employed by or under tha suponAslon of a Deemed driller, <br />registerw professional engineer or profeoslonal goolog,* <br />Contort / Company /24M Ar wg/ a CC dry <br />Address 6 a, lox /9f <br />City, State b 7Jp _f/an 9, C© L <br />Phone -l_?-! P-y0elle pax 7/- <br />Location: NW '/A '/+, Sedan <br />Township /S(]N Cn, Range w'-,P 01219W, j 411A <br />County ? T <br />Subdivision, Lot, Blk. Fig (as applicable) <br />Site/PX Addmss <br />GPs Location In UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />the distance unity. ?Zone 12 or ]Zone 13. <br />/' Fasting Northing <br />g of Monitoring Hole(s) to be constructed: <br />Estimated Depth 7-0 Ft., Aquifer <br />Pub of Monltong Hole $ ) „-- E <br />7-AA OVSO dC FY gow "i " g Lyd <br />Anticipated Date of Constrtictlon: /J- L A2 <br />Print Name: 171C v ry U <br />Data Notice Submitted: f ?^ t? ?>fl <br />Signature: <br />(Must be at left 3 days prior t0 OonStlUOtlon) <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'$ OFFICE <br />(oll Cl 6 FOR OFFICE USE ONLY <br />MH PROCESSED 5Y <br />DIV, Z WD BAs MD DATE ACKNOWLEDGED ll - ' ?o <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 monltaring & observation hole(s). <br />2) Construction of the hole(a) must be completed within 90 days of the dote 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 rrom the State Engineer. Water diverted during testing <br />shall not be used for beneftal purposes. The owner of the hole(s) Is responsible for obtaining permll(a) and complying with all rules and <br />regulations pertetnbtg to the discharge of fluids produced during testing. <br />3) Ail work must comply with the Water Well Construction Rubs, 2 CCR 402.2. Minimum oonstruction standards must be met or a variance <br />obtained. Standard permit application and work report fonts are found on the 13WR website at htto://wRwaglio ztutexam.;. Well <br />Construction and Test Reports (GINS-31) must be completed for aoch hole drilled. The licensed contractor or auVoix.ed Individual must <br />submit the completed forms to this ofibe within 60 days of monitoring hole Gompletlon. <br />4) Unless a wall permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction, An Abandonment <br />Report (form GWS4h must be submitted within 80 days of plugging & sealing. The above MH acknowledgement number, owner's <br />structure name, and owner's name and address must be provided on aid well pamVt appllcation(e), well corlslnlctlon and abandonment reports. <br />6) The owner of the hole(s) shall maintain records of water quality testing and submit thls deft to the 5teto Engineer upon request. <br />B) A MONITORING HOLE CANNOT BE CONVIOtTED TO A PRODUCTION WATER WELL, so mpt for purposes of remedlatfon (recovery) <br />or as a penm>Anent dawatering system, if constmood In accordance with tho Water Well Construction Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITFON 90 DAYS, PLEASE WRITE. "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THrz FILE NUMBER ANP FAX THE COPY TO T"E DIVISION OF WATER RESOURCES. <br />THIS ACKNOWLEDGMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT($) CAN BE APPROVED. <br />apace for labels or additional oonditlorte