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 07:15 FROM -Colo Div of Water Resources [phone] T -508 P.003/008 F -572
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NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
Please type or print legibly In black or blue ink o lR ? e -/C
COLORADO DMSION OF WATER RESOURCES -1313 SHERMAN ST-RM 821 - DENVER -00- 80203
PHONE: [phone] —FAX: [phone]
Well Owner's Name, Addeee 8. Phone atilt ✓G r��a / / „/jrKG (©
/°.0, day /9/, d rug, ca ea %o
Landowner's Name
Please check one and complete as Indicated Including contact Info:
Water Wen Driller Licensed In Colorado -• Uc. No.
❑ Professional Engineer Registered In Colorado - Reg. No.
❑ Professional Geologist per CRS 34- 1- 201(3)
pa Other - anyone dkeotiy employed by or under the supervision of a iioermed drlllor,
registered pmrewlonal engtneer or pro :. Orel g oglall�/
Contact / Company ..!.1 6/ 4�
Address
City, State & Zip M C-717% (a
Phone 7/- jd 5 '0 9t
Print Name:
Signature:
Pax
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Location: < r W '/., 1 4, Section /6
Township �SbN IS Range ❑EX1w,Z M
County T r2te: ie..
Subdivision, Lot, Slk, Fig (as applicable)
Site/Property Address
GPS Location in UTM format (optional):
Set GPS unil to true north, datum NA083, and use meters for
the distance units, CZone 12 or OZone 13.
Eastlng Northing
# of Monitoring Holes to be constructed: /
Estimated Depth Ft., Aquifer
Purpose of Monitoring Holes) Z .vi
Anticipated Data of Construction:
Date Notice Submitted: /2- 0 / Q —/O
(Must be et least 3 days prior to construction)
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
2°-c � FOR OFFICE USE ONLY
- MH PROCESSED BY
DIY, WD 1` HAS MD DATE } AcKNOwLEDGED r • le • l d
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRiLUNG SIT@.
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 00 days of the date notice was given to the State Engineer. Testing and/or
pumping shall not exceed 8 total of 200 hours unless prior written approval Is obtained fram the Stale Engineer, Water diverted during testing
!MUM be used for beneficial purposes, The owner of the hole(,) is responsible for obtaining permil(R) and complying with ail rules and
regulations pertaining to the discharge of Quids 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 webslle at Jtdo•ihrww.watef. tgte.co.►ut. Well
Construction and Teat Reports (GW5.31) muai be completed for each he drilled. The licensed contractor or authorized Individual must
submit the completed forms to this office within 60 days or monitoring hole oompletion.
Unless a well permit is obtained, the hote(s) must be plugged and sealed within one (1) year after construction. An Abandonment
Report (form GW5.9) must be submitted within 80 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 app(cadon(s), well construction and abandonment reports.
5) The owner of the hole(s) shall maintain records of water quality tasting end submit title data to the State Engineer upon request.
6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL„ except for purposes of rermediation (recovery)
or as a permanent dewatering system, if constructed In accordance with the Water Well Construction Rules and policies of tho State
Engineer.
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A
COPY OP 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.
3
(Use above apace for 'abate or additional conditions as needed)