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DEC-09-2005 TUE 04:50 PM <br />P. 08 <br />RECEIVED <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please type or print legibly in black or blue Ink <br />DEC 10 = <br />REMUES <br />INSURER <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203 MUT ST?TE EM61YEER <br />COLO <br />Contact Jeremy Deuto. P.G. <br />Company Tetra Tech <br />Address 1 X00 South. Sunset Street. <br />Suite IF <br />City, State, Zip Lonamont. CO 8!1,501 <br />Phone 303-772-6282 Fax No. 303-772-7039 <br />Driller Lic. No. (1f applicable) <br />Name Lafarge North Amelige <br />Address 10170 Church Ranch Way. Suite 200 <br />Woltminstar. CO 80021 <br />Well Owner's Phones 303.857.4000 <br />FAX NO. 3037727039 <br />Location: h? %, SE'/•,, Sectlon Al <br />Township §bLN / S, Range M E / W, PM <br />County Weld <br />Subdivision <br />Lot . Blk. Fig. <br />SRWProperty Address 5011 F Street <br />Greeley CO 80631 <br />Hole(s) to be constructed: Number i-i <br />Estimated depth M Ft. Aquifer <br />Purpose of Monitoring Hole(s) Groundwater <br />Approximate Date of Construction 12-15-2008 <br />(fit be at RMt3 days prior to corSWucd0n) <br />Landowner's Name: _ Tim Iverson Jeremy Deuto <br />Authorized Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />4 8 X 0 FOR OFFICE USE ONLY <br />MH- <br /> <br />Div. I WD-,3BAS MD <br /> <br />DATE ACKNOWLEDGED ° E3 <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 94 days of the date. notice was given to the State Engineer. Testing and/or pumping shall not <br />exceed a total of 200 hours unless prior written approval Is obtained from the State Engineer. Water diverted during testing all otn 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 standards must be met or a <br />variance obtained. Standard permit application and work report forms are found on the DWR websi a at httaJlwww.water.statt.co.us. <br />Well Construction and Test Reports (OWS-31) must be completed for each hole drilled. The licensed contractor or authorized Individual <br />must submit the completed forms to this office within 80 days of drilling. <br />Unless a well permit -I* obtained, the hole(s) must be plugged and sealed within one (1) year after construction. <br />An Abandonment Report (form GWS4) must be submitted for each hole plugged with 60 days of plugging & sealing. The <br />monitoring hole acknowledgement number, owner's structure name, and hole owner's name and address must be provided on all well <br />permit application(s), well 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 remediallon (recovery) or as a permanent <br />Dewatering system, If constructed In accordance with the Water Well Construction Rules and policies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE 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 ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER <br />PROCESSED BY