2011-01-20_HYDROLOGY - M1980244 (2)

Home Browse Search

J2 -10 -10 Gwa.e1 oenooe 07:18 FROM -Colo Div of Water Resources +3038663589 T -508 P 008/008 F -572 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) Roue type or print legibly In blank or blue Ink Q IA 88-a COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821-DENVER-00-80203 PHONE 303- 866.3581 —FAX; 303.856.3589 Well Owner's Name, Addre & Phone C61 I/4u) � / vi s� Co /' � r day-19e I c D CO eG+d'bD Landowner's Name C G ai• V 491.4 /7/H/ ce Pleura cheek one and complete es indicated Including contact Info: ❑ Water Well Driller Licensed In Colorado - Uc. No. ❑ Professional Engineer Registered in Colorado - Reg. No. Q Professional Geologist per CRS 341. 201(3) pa Other - anyone directly employed by or under lute supervtelan of a licensed driller, registered professional engineer orprosloral gm Deist /" Contact/ Company �itAf UA ( j li Gi , // erc /2(' Address A a. 4, 17/ City, state a Zip cft ?Co Phone 7/ 9 JO5- -4'Qft Fax 7 / 'La:I 14Y Print Name; / 41 eA r.10 es" Signature: AIC KNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE 5 5 � FOR OFFICE USE ONLY L /,j'� `t � - MH PROCESSED BY 4? D iv. 1— WD ft- SAS MD ) ) Location: I li k st '/ ,j y,, Section 0 ,L Township LOON Ns, Range 69 ❑E&]W, "'PM County l 2 Subdivision, Lot, Blk, Flg (es applicable) 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 ❑Zone 13. Fasting Northing # of Monitoring Hotel9 be constructed: Estimated Depth <60/ Ft., Aquifer Purpose of Monitoring Hole(s) /764 71:24/ /474.- Anticipated Date of Construction; - - /-- /e7 Date Notice Submitted: /2" Q ( Must be et least 3 days prior to consirucilon) DATE ACKNOWLEDGED 1 I ( • ( 0 CONDl71ONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. 1) Nonce was provided to the State Engineer at least 3 days prior to construction or monitoring & observation hole(s). 2) Construction of the holes) must ha completed within pa d vat of the date notice was given to the State Engineer. Tasting and/or pumping shall not exceed a total of 200 hours unless prier written approval is obtained from the State Engineer. Water diverted during testing &hglLaot be used for beneficial purposes. The owner of the hole(s) Is resporsgible for obtaining permtt(s) and oomplying with all rules and regulations pertaining b the discharge of fluids produced during testing. 3) All work must comply with the Water Weil Construction Rules, 2 CCR 402-2, Minimum construction standards must be met or a variance obtained. Standard penult application and work report forma are found on the DWR wabsfle at bttorrlmny tvaror stste.co,us. Well Construction and Tea Reports (GWS -31) must be completed for eaoh hole drilled, The licensed contractor or authorized individual muei submit the completed fon'ns to this office within SO 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-6) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's structure name, and owner's narpe and address muss be provided an all wall permit appllaatton(s). well construction and abandonment reports. 5) The owner of the holes) shall maintain records of water quality testing and subunit this data to the State Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remedlation (recovery) or es a permanent dewatering system, If constructed in accordance with the Water Well Construetlon Rules and policies of the State Engineer. IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 00 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 PERMIT(S) CAN BE APPROVED. (Use above apace for labels or additional conditions es needed)