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12 -10 -10 <br />07:14 FROM -Colo Div of Water Resources +3038663589 T -508 P 002/008 F -572 <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />winos Please type or print legibly In black or blue ink 0.1-4 6 ,9 -/S" <br />COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST•RM 821- DENVER -00-80203 <br />PHONE: 303 -866- 3581 --FAX! 303 -866 -3589 <br />Location: f!t y. ''A, Section / / 6 <br />Township ❑N i$[s, Range 6p OE,wW, r PM <br />County re <br />Subdivision, Lot, Bik, Flg (as applicable) <br />GW8,1 <br />Well Owner's Name, Addees & Phone ee l Vt asz ./3.04 <br />(© <br />14, lox /9/, 1 cry CD ePo be_ <br />Landowner's Nemo I_ G r� �I�uJ /N /M7 <br />Please cheek ono and complete as indicated including contact Info; <br />❑ Water Well Driller Licensed In Colorado - Uo. No. <br />❑ Professional Engineer Registered in Colorado - Reg. No. <br />❑ Professional Geologist per CRS 341- 201(3) <br />Other - anyone directly employed by or under the supervision of a licensed driller. <br />registered professional engineer or pro tonal ge .. agist <br />Contact/ Company <br />Address A a. /9/ <br />City, State B,Zip Grvo.,,_'O cP0 ?c <br />Phone 7/5- 03-4'0 5/ Fax ZJ 9- ` .1 s 7 <br />Print Nome: / (7w <br />Signature: <br />3 <br />Site /Property Address <br />GPS Location In UTM format (optional): <br />Sat GPS unit to true earth, datum NAD83, and use meters for <br />the distance unite, QZ,one 12 or ❑Zone 13. <br />Eastine Northing <br />tl of Monitoring Holes to be constructed; , l <br />Estimated Depth QPt., Aquifer <br />Purpose of Monitoring Hote(s) "law reetovi4 <br />Anticipated Date of Construction: / o <br />Date Notice Submitted: /2 <br />(Must be at least 3 days prior to construction) <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE: USE ONLY <br />MH PROCESSED BY <br />DIV. L _ WO 112— BA8 MD DATE ACKNOWLEDGED 1 2- (O` 10 <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALT. BE AVAILABLE AT THE DRILLING SITE <br />1) Notice was provided to the State Engineer et least 3 days prior to construction of monitoring & observation hole(s). <br />2) Construction of the boles) must be completed within 90 dove of the data notice was given to the State Engineer. Teseng and /or <br />pumping shall not exoeed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during tasting <br />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 <br />regufatlone pertaining to the discharge of fluids produced during testing. <br />3) All work must comply with the Water Wall Construction Rules, 2 CCR 402 Minimum construction standards must be met or a variance <br />obtained. Standard permit application and work report forts are found on tha DWR webstte at bliplitinvrarlistonnicethill. Well <br />Construction and Test Reports (GWS47) must be completed for each hole drilled. The licensed contractor or authorized individual must <br />submit the completed forms to this office within 80 days of monitoring hole completion. <br />4) Unless a well permit la obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment <br />Report (form GWS-9) must be submitted within 60 days of plugging & sealing. The above Mil acknowledgement number. owner's <br />etruotura name, and cwnare name and address must be provided on ea well permit epplloation(s), well construction and abandonment reports. <br />5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request. <br />13) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remedfation (recovery) <br />or as a permanent dewatering system, if constructed In accordance with the Water Well Construction Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WiTHIN 00 PAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />THIS ACKNOWLEDGEMENT OP NOTICE DOES NOT INDICATE THAT WELL PERMiT(s) CM BE APPROVED. <br />(Use above space for labels or eddlUonel conditions as needod) <br />