2011-01-20_HYDROLOGY - M1980244 ‎(2)‎

• Permit No: M1980244
• IBM Index Class Name: HYDROLOGY
• Doc Date: 1/20/2011
• Doc Name: Notice of Intent to Construct Monitoring Wells.
• From: CC&V
• To: DWR
• Permit Index Doc Type: Hydrology Report
• Email Name: BMK
• Media Type: D
• Archive: No

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Print Name:
Signature:
Div. '2.- um 6 Z
FKUiHbolo Ulv of Water Resources
[phone] T -409 P.002/002 F -303
NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
Please type or print legibly in black or blue ink 4 , / -. O
COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST-RM 821-DENVER-00-80203
PHONE: [phone] --FAX; 303 - 886 -3689
Location: _ 1 /. t Y, Section /
Township a r IN j$S, Range 69 ❑EA1N, 6j 8 PM
County 7w
Subdivision, Lot, Rik, Fig (as applicable) �/4
WoII Owners Name, Address & Phone CC 9" Ato/^'v f O
/?2Bq% /9/� Yi Co r�e6o
Landowner's Name ` / C ti`LV 4124a Ir✓/ Cc,
Please chock one and complete as indicated including contact Info:
ID Water Well Driller Licensed in Colorado — Uc. No.
❑ Professional Engineer Registered in Colorado — Reg. No.
❑ Professional Geologist per CRS 34-1-201(3)
alter professional - anyone directly employed by or under the supervision of a licensed driller,
letered professional neer Or professional geol let
Contact / Company /M6 4/✓ow l / A- - V� , Pr...D/2N /r (
Address A O, QQxI g/
City, stars & Zip V /4-7943 Co cita P O
Phone 7/7 ra dP 9D4/ Fax 7/9 - 617-3,147
.0 - z/voe/
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
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t , ¢ FOR OFFICE USE ONLY
[ '( D MH PROCESSED BV
Stte/Property Address /EL e Q Cci., 4 /2o14
CPS Location in UTM format (optional):
Set GPS unit to true north. datum NAD83, and use meters for
the distance units, ❑Zone 12 or )]zone 13,
Easting Northing
# of Monitoring Hole(s) to be constructed:
Estimated Depth 2t,, Aquifer
Purpose of Monitoring Hole(s) 7O .es a- .0 vre
Anticipated Date of Construction; l/" I- - / O
Date Notice Submitted: // — 49, — /C3
(Must be at west 3 days prior to cons,rucUon)
BAs MD DATE ACKNOWLEDGED it - q 10
CONDmONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE.
1) Notice was provided to the State Engineer at least 3 clays prior to construction of monitoring & observation hole(s).
2) Construetlen of the hole(s) must be completed within 90 days of the date notice was given to the State Engineer. Testing and/or
pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing
gbiji,po be used for beneficial purposes. The owner of the hole(s) Is responsible for obtaining permit(s) and complying with all rules and
regulations pertaining to the discharge of flub produced during testing.
3) All work must comply with the Water Well Construction Rutea, 2 CCR 402.2. Minimum construotlon standards must be met or a variance
obtained. Standard permit application and work report forms are found on the DWR wsbslte at htty: «wt y,wator.statc.ao.ue. Weil
Construction and Test Reports (GWS -31) must be completed for each hole drilled. The licensed contractor or authorized individual must
submit the completed forms to this office within 80 days of monitoring hole completion.
4) Unless a well permit le obtained, the holes) must be plugged and seared within ono (1) your attorconstruction. An Abandonment
Report (form GWS-9) must be submitted within 60 days of plugging & sealing. The above MH aolclowledgernent number, owner's
structure name, and owners name and address must be provided on all well permit application(s), well construction and abandonment reports,
6) The owner of the hole(e) shall maintain records of water quality testing and submit this data to the State Engineer upon request.
8) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of ramediotion (recovery)
or as a permanent dewatering system, If constructed In accordance with the Water Well Construction Rules and policies of the State
Engineer,
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WrrHlN 90 PAYS, PLEASE WRiTE, "NO HOLES CONSTRUCTED" ON A
COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND WINE COPY TO THE DIVISION OF WATER RESOURCES,
THiS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(s) CAN BE APPROVED.
(Use above space for labels or additional oonditions as needed