2011-01-20_HYDROLOGY - M1980244 (2)

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•11 -18 -10 Signature: 07:10 FROM -Colo Div of Water Resources +3038663589 T -450 P 001 /001 F -403 Ow8.51 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) 0812008 Please type or print legibly In black or blue Ink O COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821-DENVER-00-80203 PHONE 303.8e6- 3581 —FAX; 303- 866 -3580 v /.a9,,Bgb /9/ UI,CO IF Landowner's Name Please cheek one and complete as Indicated Including contact Info: ❑ Water Well Driller Licensed In Colorado - Lis No. O Professional Engineer Registered in Colorado - Reg. No. O Professional Geologist per CRS 34-1-201(3) g other stered - anyon eselorel enge dkedty ineer o employed r by or under oto the gist auparvIaion of e licensed driller, g l prof lxo ga Contact / Company CGe!/4..ro /2.4,..,6 Address f ` O ff , )o /9/ ' City, Sista & Zip 4r04 Phone 7 /9- -616 —Vote Fax 7 4 „,,a',/ Print Name: V i f Well Owner's Name, Address & Phone 64 ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE USE ONLY - MH PROCESSED BY Div, WD BAS MD DATE ACKNOWLEDGED tt' 1 D CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRIWNG SITE. 1) Notice was provided to the State Engineer at least 3 days prior to constntction of monitoring & observation hole(s). 2) Construction of the hole(s) must be completed within 90 days of the data notice was ghren to the State Engineer. Testing and/or pumping shall not exceed a total of 200 hours unless prior written approval is obtained front the State Engineer, Water diverted during testing ghglIzet be used for beneficial purposes, The owner of the hole(s) le responsible for oblalning permit(s) and complying with all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum construction standards must be mot or a variance obtained. Standard permit application and work report forms are found on the DWR webelte at htlul/rwww.water.state.ce.ut. Well Construction and Test Reports (GWS31) must be completed for each hole drilled. The licensed contractor or authorized Individual must eubmlt the ooapleted forms to this office within 80 days of monitoring hole completion. 4 ) Unless a well permit fa obtained, the hole(s) must be plugged and sealed within ono (1) year after construction. An Abandonment Report (form GWS■9) must be submitted within 80 days of plugging & sealing. The above MH aoknowledgement number, owners structure name, and owner's name and address must be provided on all well permit epplicadon(s), well construction and abandonment reports. 5) The owner of the hole(a) 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 mmediatlon (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 WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED” ON A COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. Location: / 1 y, -SO K. Section / Township , f„CON P. Range 69 ❑E WV. 6M County Subdivision, Lot. Blk, FIg (a applicable) .evt4a Site /Property Address 7.1:74164_C—e9422...? ✓1Y GPS Location in UTM format (optional): Set GPS unit to true north, datum NAD83, and use meters for the distance unite, Ozone 12 or ❑ Zone 13. Easting Northing # of Monitoring Hole(s) to be constructed; Estimated Depth 7J FL, Aquifer Purpose of Monitoring Fiole(s) T 8E aidrEa2 /0"illO /1c,Cre 44// rig/210W G✓ist-c- Anticlpetod Date of Construction: // /9 7/ Date Notice Submitted: /1- /6 —/ d (Must be at least 3 days prior to construction) (Use above space for lebois or addittonel conditions as needed)