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 07:17 FROM -Colo Div of Water Resources
aw5-51 NOTICE OF INTENT TO CONSTRUCT MONITORING I IOLE(S)
mums Please type or print legibly In black or blue Ink S4 eo' -/7
COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821.-DENVER-00-80203
PHONE: 303- 866 - 3581 —FAX: 303 - 8664588
Location: - ''A / _ '/,, Section l 7
Township /S[)N L$S. Range 69 (]EzW, 6 F PM
County - '7`` t'z
Subdivision, Lot, 81k, Flg (as appUoable)
Well Owner's Name, Address & Phone Cd ✓ nuns i /,✓/ CO
/D, der 1 crrse, � Co Fa"
Landowner's Name CC L v 4.04.0 /7 /N/ (2
Pleaao chock one and complete as Indicated including contact Info:
O Water Well Driller Licensed In Colorado - Llo. No.
❑ Professional Engineer Registered In Colorado - Reg. No.
❑ Professional Geologist per CRS 34-1- 201(3)
fa Other - anyone directly employed by or under the supervision of e licensed driller.
registered professional engineer or g (ogle/ /�
Content / Company /i94r £ fie V 1 / /•••64 , O
Address
City, State & 21p c rV4 ( 'O
9
Phone 7/ 9- 609 ypyfi Fax 7/
Print Name:
Signature;
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
FOR OFFICE USE ONLY
6 t my MH PROCESSED BY
Div. Z WD 1 7i
1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & obeervadon 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 to obtained from the State Engineer. Water diverted during testing
Thal{ not be used for beneficial purposes. The owner of the hole(e) is responsible for obtaining permit(s) end complying with all rules and
regidatlona pertaining to the discharge of fluids produced during testing.
3) All work must comply with the Water WaII Construction Rules, 2 CCR 4024. Minimum construction standards must be met or a variance
obtained. Standard permit application and work report forma are found on the DWR website at hno /hnv yr�mr gatacp er. Well
Construction and Teat 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 80 days of monitoring hole completion.
Unless a wall 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 8D days of plugging & sealing. The above MH acknowledgement number, owner's
structure name, and owner's name and address must be provided on all wall permit application(e), well construction and abandonment reports.
5) The owner of the hole(a) shall maintain records evader quality tasting and submit this data to tho 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 Conetrustlon Rules and policies of the State
Engineer.
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 99 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A
COPY OF THE ACKNOWLEDGED NOTICE WRH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES.
THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELT. PERMIT(S) CAN BE APPROVED.
)
Aoc
cP9 24 r7
[phone] T -508 P.006/008 F -572
Site/Property Address
GPS Location In UTM format (optional):
Set GPS unit to true north. datum NA083, and use meters for
the distance units, ❑Zone '12 or []Zone 13.
t=esting , Northing
# of Monitoring Hole(s) be constructed;
<&0 Estimated Depth < Ft, Aquifer
Purpose of Monitoring Hole(s) "A/I719/2 /0.4 h/'tC.
Anticipated Date of Construction: / -6249—
Date Notice Submitted; /2" O9 /O
BAS MD DATE ACKNOWLEDGED 1 Z -1 O- I 0
(Must be al least 3 days prior to construction)
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHAW. BE AVAii.ABLE AT THE DRIWNG SITE.
(Use above epace for labels or additional conditions as needed)