2011-01-20_HYDROLOGY - M1980244 (2)

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GWS -51 08 /2008 Please type or print legibly in black or blue ink Landowner's Name O.4 - /9/ City, State & Zip (_7V Ca Phone 7/ Gd5 4'O5' Address Print Name: Signature: NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) o rev 8 / 9 / COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821- DENVER -00-80203 PHONE. 303 - 866 - 3581 -- -FAX. 303 - 866 -3589 5-6:- ,., /� Location: 'A / , 1 y, Section / 7 Township /S❑N cgS, Range 6p ❑Ekrw, 6 7- 1"M County ` �?iLt 2 Subdivision, Lot, Bik, Flg (as applicable) Well Owner's Name, Addres & Phone Cc ? VG Je_D / / „/1/4 (O QOX /9/, 4 C r OP CO oPpe6,0 C C (/ / . /A/ /, CO Please check one and complete as indicated including contact info. ❑ Water Well Driller Licensed in Colorado - Lic No. ❑ Professional Engineer Registered in Colorado - Reg. No. ❑ Professional Geologist per CRS 34 -1- 201(3) Other - anyone directly employed by or under the supervision of a licensed driller, registered professional engineer or professional ge logist // cD /l Contact / Company 4.4.k. 4.4.k. G!� i4 CC d/" Go /� ,04'(Q doP60 y Fax 7/ / r t�+f/ '.)'Z.S Site /Property Address GPS 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 Hole(s Aquifer Purpose of Monitoring Hole(s) / L✓�/2_ ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE USE ONLY M H PROCESSED BY Div. WD BAS MD DATE ACKNOWLEDGED CONDITIONS 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 days prior to construction of monitoring & observation hole(s). 2) Construction 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 dunng testing shall not 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 fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402 -2. Minimum construction standards must be met or a variance obtained. Standard permit application and work report forms are found on the DWR website at http:iin«w.water.state,co.ru. Well 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 60 days of monitoring hole completion. 4) Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment Report (form GWS -9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's structure name, and owner's name and address must be provided on all well permit application(s), well construction and abandonment reports. 5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediation (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. Anticipated Date of Construction: /2- -.20 Date Notice Submitted: /2" 9 (Must be at least 3 days prior to construction) (Use above space for labels or additional conditions as needed)