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DEC-09-2009 TUE 04:49 PM <br />FAX NO. 3037727039 RECEIV& <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please "a or print legibly in bledc or blue ink <br />Colorado Division of Water Resources 1313 Sherman St-Room 821 Denver CO 80203 <br />Plump 3rnMF;A 3581 Fax 3n% AaR-4RR4 <br />BEC 10 901 <br />"MTE 0601FA <br />Cato <br />AUTHORIZED INDIVIDUAL O DRILLER <br />Location: CIF T/., W14, Section AU <br />Contact Jeremy Deuto. P.G. Township O &N / S, Range 66 , E / W. PM <br />Company Tetra Teat County Mid <br />Address 1900 South. Sunset Street, <br />Suite IF Subdivision <br />City, State, Zip Lonamont. CO 8001 Lot. Blk. . Fig. <br />Phone 303-772-5282 Fax No. 303-772-7039 <br />Driller Lic. No. (If applicable) Site/Property Address WA <br />Well Owner (Client) Information Hole(s) to be constructed: Number'. ? ?? <br />Name Lafarge North America Estimated depth V Ft. Aquifer <br />Address 10170 Church Ranch Way. Suite 200 Purpose of Monitoring Hole(s) Groundwater <br />Westminster. CO 80021 monitoring <br /> <br /> Approximate Date of Construction 1&10.2008 <br /> (Must be at least 3 days prior to Construction) <br />Well Owner's Phones 303-667-4000 <br />Landowners Name: City Of Grelley Jeremy Deuto <br /> Authorized Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />04826,7 FOR OFFICE USE ONLY <br />MH- PROCESSED BY,r <br />Div. WD ?3_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 />Notice was provided to the State Engineer at feast 3 days prior to construction of monitoring 3 observation hole(s). Construction <br />of the hole(s) must be completed with 90 days of the date notice was ghren 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 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 />pertalning to the discharge of fluids produced during testing. <br />All worst must comply with the Water Wall Construction Rules, 2 CCR 402-2. Minlmum construction standards must be met or a <br />variance obtained. Standard permit application and work report forms are found on the DWR websits at (rttP**-VM .water stats.co.us- <br />Weil Construction and Test Reports (GWS-31) must be completed for each hole drilled. The Itoensed 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 within one (1) year after construction. <br />An Abandonment Report (form GWS-9) must be submitted for each hole plugged with eo days of plugging & seating. The <br />monitoring hole acknowledgement number, owner's structure name, and hole owners 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 remediatfon (recovery) or as a permanent <br />DewMtering system, if constructed in accordance with the Water Well Construction Rules and policies of the State Engineor. <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 WrrHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED' <br />ON A COPY OF THE DG A NQTICC WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER <br />RESOURCES. q Lif,.4 I„A ti „-*o,