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

01 -03 -11 06:55 FROM-Colo Div of Water Resources
[phone] T -547 P 001 /001 F -731
°s 6
t�,v NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
Please type or print legibly in black or blue ink
COLORADO DIVISION OF WATER RESOURCES -1313 SHERpMAN ST•RM 821-DENVER-CO-60203
PHONE [phone] —FAX: [phone]
Well Owner's Name, Address & Phone ‘.O ZACe a 6
I4?- B !� eo'0 ( O
Landowner's Name C.C-Tic rirda‘D "i01./
Please check one and c omplete as Inthcated Including contact Info:
❑ Water Well Driller licensed In Colorado - Uo. No.
❑ Professional Engineer Registered In Colorado - Reg. No,
❑ Profs Sional Geologist per CRS 34- 1- 201(3)
Other -anyone directly employed by or under the supervision of a ikensed drtha
registered professional e i . er sr proles tonal geologist
Contsot / Company 4 . i G OW
Addresa 1, D, AN^ 19/
city, stale & 2Ip e.TD ( Aodt p
Phone 7/ 6 t9 Ycr Fax 719` eri �-.� �'�
Print Name: "IL( 1 /1///1 x /
Signature:
'I 1 SG S
/Ira
AC NOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
FOR OFFICE USE ONLY
M PROCESSED BY
Location: &C. ,A 4/14 y Section
Township &LIN Xs, Range ( / PE [9y/, ‘ZSM
County erL,Le
Subdivision, Lot, Mk, Fig (as applicable)
Slte/PropertyAddress 63v011,42.2?-1
GPS Location In UTM format (optional):
to e orth
n , , and
th e d OPS istanw unit units [] Zone datum 12 or [)Zo 13e. use meters for
Eating --- Northing
N o f Monitorin Hole(e) to be constructed; ,
Eot D ept h ?S Aquifer
Purpose of Monitoring Hole(s) 72/ /r C 4 4 0.+ly es=
Antidpated Date of Construction:
Date Notice Submitted: _ L "3 7
(Must be Wisest 3 days prior to construction)
Of— O,1'-/
Div. L- WD i 1--- BAs MD DATE ACKNOWLEDGED � 1.5 - 4 l
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING 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) must be completed within 90 days of the data notice was given to the State Engineer. Testing and/or
pumping shall not exceed a total of 200 hours cutlass prior written approval Is obtained from the Slate Engineer
shall not be used for benaflpial purposes The comer of the hole g Permll {s) s} is reeponstble for obtaining and 1 i n g diverted during t
regulations pertaining to the discharge of fluids produced during testing. and complying with all rules and
3) All work must comply with the Water Well Construction Rules, 2 CCR 402 Minimum construction standards must be net or a variance
obtained. Standard permit application and work report forms are found on the DWR webeite at kngt/Avew,waterAutawa, Well
Construction and Tad Reports (GWS.37) must be completed for each hole drilled. Tha licensed contractor or authorized Individual must
submit the completed forme to this oboe within 60 days of monitortng hale completion.
4) Unless a well permit k obtained, the hole() must be plugged and sealed within an (1) year after construction. An Abandonment
Report (form GWS-9) must be submitted within 60 days of plugging & sealing. The above MH
structure Hams, and owner's name and address must be acknowledgement number, owner's
The owner of the h provided on el wal penult appllcation(s), well construction end abandonment reports,
helots) 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
or as a permanent dewatering ayatem, If constructed In accordance with the Wader We& Construction s and policies f State
Engineer. ruction Rules and Policies of the Staate
7) IF HOLES WiLL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS. PLEASE WRITE, 0 NO HOLES CONSTRUCTtt!p" 0M A
COPY op THE ACKNOWLEDGED NOTrCE Wr1H THE FILE NUMBER AND FAX 71fS COPY TO THE DnnSioN OF WATER R as URces.
THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED.
(Use above spans for labels or attditional conditions as needed}