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 -16 07:16 FROM -Colo Div of Water Resources
GWS.s1
Oir24011
DiV. z- WD 17-
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[phone] T -508 P.005/008 F -572
NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
Please type or print legibly in black or blue ink a0 •°/Q B# — 1 u
COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821-DENVER-00-80203
PHONE: [phone]—FAX: [phone] ,_/ /
Lootdion: . 511/ 14 / 'h Section / 7
Township L NS. Range � ❑EK‘N. (o M
County T e?.4t i2.
Subdivision, Lot, Elk, Fig (as applicable)
Well Owner's Name, Addresp & Phone Cel V4 40 4,
/ ldx 191 k5CTV, Cabo
Landowner's Name 4 �i�✓ /.� t�0
Please check one and complete as Indicated Including contact Info:
O Water Well Driller Licensed in Colorado - Uc. No,
❑ Professional Engineer Registered In Colorado - Reg. No.
0 Professional Geologist per CRS 34-1 - 201(3)
Other -anyone dIreoUy employed by or under the supervision or a licensed drllier,
gletered professional engineer or professional ge logiel �j
Contact / Company / lA,& 1(4,424 (cC le nc /�+i 'C
Address , /c ( .4)1C 19J
City, State a Zip $ e, y o ? o
Phone 719- ‘d 4 4.'OfQ Fax 7/ 9 4PF J'dry
Print Name:
Signature:
ACKNOW LE ' GEMENT FROM STATE ENGINEER'S OFFICE
FOR OFFICE USE ONLY
5' S 5 - MH PROCESSED BY
BAS
MD
3
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 DZone 13,
Easdng Northing
d of Monitoring Holes to be constructed: l
Estimated Depth < 6 D Ft.. Aquifer
Purpose of Monitoring Hole(s) / TOR in4 4
Anticipated Date of Construction: / ° - 4 4
Date Notice Submitted: /2 0 9 - 70
(Must be al least 3 days prior to construction)
DATE ACKNOWLEDGED 1 2 `(0- r o
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 construction of monitoring & observation hole(s).
2) Construction of the hole(s) roust be completed within 90 cave of the date notice was given to the State Engineer. Testing and/or
pumping shall not exceed a total of 200 hours unless prior wren approval Is obtained from the State Engineer. Water diverted during testing
1&Ii apt be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining permits) and complying with all Hates 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 parrnit applloatlon and work report forms are found on the DWR website at litip://wirrw.walcr.sfatc.co.uh. Wail
Construction end Test Reports (OWS -31) must be campieted 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.
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 piths 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 polices of the Stale
Engineer.
7) W 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 ACIWOWLEDGEMENT OF NOTICE DOES NOT iNDiCATE THAT WELL PERMMIT(S) CAN BE APPROVED.
(Use above apace for labels or additional conditions as needed