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

Aft
10/14/2010 06:34 7196893254 CCVGMC
e ,„ r , NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
canoes Please type or print legibly In black or blue ink
COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST-RM 821- DENVER -CO -80203
PHONE: 303 - 866.3581 —FAX: [phone]
Well Owner's Name, Address & Phone CC i '49 A.A 4 Co
. 10 ?O /9'/ l //JT CO CO y Pee69
Landowner's Name CG ytt V `e Ate® / /ii✓ IVZ C
Please check one and complete es indicated Including contact info:
❑ Water Well Driller Licensed in Colorado - Lie. No
❑ Professional Engineer Registered in Colorado - Reg. No.
❑ Professional Geologist per CRS 34 201(3)
Zr Other - anyone directly employed by or under the supervision of s licensed driller,
registered professional en y or pror/�' onel gsolog' /�;
Contact / ComparAy /� / r : _ '� �V��� ' memo �O
Address rr o r d4x 19/
cit State & Zip V /`-Ma d CO
Phone 7 /9 - Of 70YQ
Print Name: /"A � . 0!✓/
Fax 7/ 9-a
Signature:
Location: /V/ s �_L' %, Section 7
Township /S ON %Range ❑E ROW, 61 M
County TE LL1 2
Subdivision, Lot. Blk, Flg (as a (cable)
4
Site/Property Address 7 C Y 6P-3
go
GPS Location in UTM format (optional):
Set GPS unit to true north, datum NAD83, and use melere for
the distance units, °Zone 12 or ❑Zone 13.
Easting Northing
I/ of Monitoring Hole(s) to be constricted:
Estimated Depth 7572 Ft., Aquifer
Purpose of Monitoring Hole(s) To BEeAvv1
WJAA4fL9 ge-LokY,VA 7PAJ, z
Anticipated Date of Construction:: 11"'4 /D
Date Notice Submitted: // - 47 _
(Must be at lead 3 days prior to construction)
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
11/(166 FOR OFFICE USE ONLY
MH PROCESSED BY
DIV. 2- WD 1 BAs MD DATE ACKNOWLEDGED 11 "x' (0
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE
PAGE 03/83
RECE 'VEi
tr /G 8
1) Node* was provided to the State Engineer at least 3 days pdior to construction of monitoring & observation hole(s).
2) Construction of the hole(s) must bo 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 is obtained from the State Engineer. Water diverted during testing
sha ll not be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining parmit(s) and complying with all rules end
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. Minimtml construction standards must be met or a variance
obtained. Standard permit application and work report forms are found on the DWR webstte at Bann //www,wster.state.co.a4. Well
Construction and Test Reports (GWS -31) must be completed for each hole drilled. The licensed oontractor or authorized indevldual must
submit the completed forms to this office within 60 days of monitoring hole completion.
4 ) Unless a well permit is obtained, the hole(s) must be plugged and sealed within ono (1) year after corvetxuceon. An Abandonment
Report (fore OWS4) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owns,
structure name, and owner's name and address must be provided on all well perrnit application(s), well construction and abandonment reports,
5) The owner of the hole(S) shall maintain records of water quality testing and submit this data to the Stets Engineer upon request.
8) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of rem.diatlon (recovery)
or as a permanent d.watering system, If constructed in accordance with the Water Well Construction Rules and policies of the State
Engineer.
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER Tests NOTICE WITHIN 90 DAYS, PLEASE WRITE, 140 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.
Uas above space for labels or additional conditions as needed