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DEC-09-2008 TUE 04;47 PM <br />FAX NO. 3037727039 <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please We or print legibly in black or blue ink <br />P. 02 <br />RECEIVED <br />OEC 0 2006 <br />"" ATEEU <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203 STAiE EtfirMEER <br />cow <br />rax <br />Contact Jeremy DeWg, P.G. <br />Company Tetra Tech <br />Address 1900 South. Sunset Street. <br />Suite IF <br />City, State, Zip Longmont. CO 80501 <br />Phone 303-772-5282 Fax No. 303-772-7039 <br />Driller Llc. No. (K applicable) <br />Name Lafarge North America <br />Address 10170 Church Ranch Wav: S itu a 200 <br />Westminster. CO 80021 <br />WelfOwner's Phones X03-657.4000 <br />Location; S V Y., hWl.., Section 334. <br />Township MN / S. Range §W E / W, PM <br />County Weld <br />Subdivislon <br />Lot . Slit. , Fig. <br />Site/Properly Address 5011 F Street <br />CO 3 <br />Hole(s) 0 be constructed: Number 1 <br />Estimated depth 35 Ft. Aquifer <br />Purpose of Monitoring Hole(s) Groundwater <br />monitoring <br />Approximate Date of Construction 12-15-2008 <br />. (Must beat least 8 days prior to construcdon) <br />Landowners Name: Tim Iverson Jeremy Deuto <br />Atthort ad Signature <br />MH- 048264 <br />Div. -J-WD 3 BAs MD <br />NT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />PROCEB$ED BY ?il.? ?scd?rc <br />DATE ACK aNLEDGED ?? /D ^ Oct <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). Construction <br />of the hole(s) must be completed with 90 cis of the date notice was given to the:State Engineer. Testing andlor pumping shall not <br />exceed a total of 200 hours unless priorwrttten approval is obtained from the State Engineer. Water diverted during testing,shall not be <br />used for beneficial purposes. The owner of the hole(s) Is responsible for obtaining permit(s) and complying with all rules and regulations <br />pertaining to the discharge of fluids produced during testing. <br />All work must comply with the Water Well Construction Rules, 2 CCR 402.2: Minimum construction standarda must be met or a <br />variance obtained. Standard permit application and work report forms are found on the DWR websfle at <br />Well Construction and Test Reports (GWsa. 1) must be completed for each hole drilled. The licensed contractor or authorized Individual <br />must submit the completed forms to this office within 60 days of drilling. <br />Unless a well permit Is obtained, the hole(s) must be plugged and sealed wl#ttin one (1) year after construction. <br />An Abandonment Report (form GWS.B) must be submitted for each hole plugged with so days of plugging .4 sealing. The <br />monitoring hole acknowledgement number. owners structure name, and hole owner's name and address must be provided on aq well <br />permit application(s), wall construction and abandonment reports. <br />The owner of the hole(s) should maintain records of water quality testing and submit this data to the State Engineer upon request. <br />A monitoring hole cannot be Converted to a production water well, except for purposes of remedledon (recovery) or as a permanent <br />Dawatering system, tf constructed in accordance with the Water Well Construction Rules and policies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELI. PERMIT(S) CANOE APPROVED. <br />IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE,'NO HOLES CONSTRUCTED' <br />ON A COPY OF THE ACKNOWLEDG M NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER <br />RESOURCES.