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

12 -10 -10 07:14 FROM-Colo Div of Water Resources
t:ws -st NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
oe/zooe Please type or print legibly In black or blue Ink 0 pf ,^/ L
COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821-DENVER-00-813203
PHONE: [phone] --FAX [phone] -
Location: �� �/. f.? / '4, Section 46
Township JCDN N'S, Range 69 °ERA W, 6 ' ' PM
County
Well Owner's Namo, Addres & Phone CO' V e a / „i/, Co
�0 Qo) / J,/ U crag , CO ei9,160
Landowner's Namo ___CLLL
Please check one and complete as indicated lnoluding contact info:
❑ Water Well Driller licensed In Colorado - Uc. No.
❑ Professional Engineer Registered in Colorado - Reg. No,
(] Professional Geologist per CRS 34- 1- 201(3)
pa Other - anyone dinutfy employed by or under the supervision of a licensed driller,
reglgt rec professional engineer or projnelonal ge Ist /y
Contact / Company /744 / p"4:24 rC f Ica / '67
Address / e O, 4x /9/
Cit Stets &
Phone OS - 405e Fax j/ 9^ a :. -'f
/ Z
Print Name:
Signature:
6'-•" N/
3
[phone]
T -508 P 001 F -572
Subdivision, Lot, Mk, FIg (applicable)
Site/Property Address
GPS Location in UTM format (optional):
Set GPS unit to true north, datum NAD83, and use meters for
the distance unris, DZone 12 or 02one 13.
Easttng Northing
0 of Monitoring Holo(�s to be constructed;
Estimated Depth <60 Ft., Aquifer
Purpose of Monitoring Hole(s) /at// T0210✓4 4 /-
Anticipated Date of Construction: e % C /
Date Notice Submitted: /2^ 0 /^ /O
(Must be at leant 3 days prior to construction)
•
ACKN a LEDGEMENT FROM STATE ENGINEER'S OFFICE
q ^ FOR OFFICE USE ONLY
G - MH PROCESSED BY
Div, 2 WD IZ BAS MD DATE ACKNOWLEDGED • fO - JO
CONDITIONS OF MONITORING KOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL 131E AVAILABLE AT THE DRILLING SrrE.
1) Notice was provtded to the Stale Engineer at least 3 days prior to construction of monitoring 8 observation hole(s).
2) Construction of the holes) must be completed within 90 days of the date notice was given to the State Engineer. Testing andior
pumping shat not exceed a total of 200 hours unless prior written approval Is obtained from the State Engineer. Water diverted during testing
shall noj be used for beneflolal purposes. The owner of the hafo(s) Is responsible for obtaining permlt(s) and complying with ell Hiles and
regulations pertaining to the discharge of fluids produced during testing,
3) All work must comply with the Water Well Construction Ruses, 2 CCR 402-2. Minimum c onstruotlon standards muss be met or a variance
obtained. Standard permit appticodon and wont report forms ere found on the DWR webslte at litio://www.miter.stett.ee.es- Well
Construction and Teat Reports (GW5 -31) must be completed for each hole drilled. The licensed contractor or authorized Individual muss
aubmlt the completed forma to this oMoe 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 appllcation(a), well construction and abandonment reports,
6) The owner of the hole(s) shall maintain records of wafer 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 accondctnes with the Water Well Construction Rules and policies of the Stale
Engineer.
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN De 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 PERMITS) CAN BE APPROVED.
Use above space for labels or additional conditions ae needed)