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

U I -12 -11
G
08120118
Well Owner's Neims Address & Phone
Print Name:
Signature:
11:42 FROM - Colo Div of Water Resources
Dlv. L - WD ( 1-
[phone] T -572 P 001/002 F -830
NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
Please type or pmt legibly In black or blue Ink // /fir Va /00
COLORADO DIVISION OF WATER RESoURcEs4si3 SHERMAN $T- RM �? f1121- DENVER.00.802p3
PHONE: [phone] --FAX: [phone]
Landowner's Name
Please check one and complete as indicated Including contact info:
❑ Wei Well Driller Licensed In Colorado - Um No,
❑ Anal EngkleW bred In Colorado - Rag. No. ___
❑ Professional Geologist per CRS 34-1.201(3)
Lat -anyone directly employed by or under the aupendslon ore Nceneed drifter,
Professional eng - - r or profess . nrrl geologist
Contact / Company � 4 ' 9
Address
City, State & Zip
Phone 7(P-- 61f -2-- feQ Yd?'
a
Fax ___242
ACKNOWLEDGEMENT FROM STATE ENGINEERS OFFICE
FOR OFFICE USE ONLY
MH PROCESSED BY
Loan: _L,�V- �.. 3 Y Section
Township SON (RangsALQE ,.6, 'M
Subdivision, Lot, BlIc. Fig (a
Site/Property Address 77r
/A.
t -ormm aetvr, 1?
GPS Location In um format (optional):
Set GPS unit to true north, datum NAD83, and use meters for
the distance units, [)Zone 12 or ID2ons 13.
Fasting Northing
# of Monitoring Hotels) to be constructed:
Estimated Depth Zig ft., Aquifer
of Ong HoI*) >{i2 ,914 .
i
Anticipated Date of construction: 0/"1, = 1/
Date Notice submitted: ®/— - //
(Must be at laset 3 days prior to comb's:son)
I - L'-
MD DATE ACKNOWLEDGED
CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT
A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL 8E AVAILAELE AT THE DRR.uNG SITE.
1) Notice was provided to the state Engineer at least 3 deism prior to conatnmlton of monitor) &
2) Construction of the hole(s) must be completed h observation hots T
pumping shall not exceed a total of 200 hours unless prior written a of the cats metier was given to tits Stria Engineer. Testing and/or
ffi�4! be used for beneficial Purposes. The ow ner of the PProvel Is obtained from the State Engineer. Water diverted during testing
shat n ldufs e hole(s) Is responsible for obtaining pemiN(s) and =plying with all rules and
Pig to the &charge of produced dump tasting.
3) All won$ nhtit COInPly with the der Welt Construcgon Rules, 2 CCR 402.2, Minimum permit to m standards moat be met or a variance
obtained. Standard permit
apphottion and work report forms are found on the DWR webslle at eignagm cauraffutsm. W
Construcgon and Teat Reports (GWS -31) must be completed for each hate drMed. The licensed contractor or authorized Individual must
aubrntt the completed forms to Ns office %thin 60 days of monitoring hole completion.
4) Unless a wee permit le obtained, the hoists) must be plugged and seated within ons 7
Report (form 01411141) must be submitted waft' 60 () > M sack eo led a t. u er, owner's
structure trams, and owner's name and address must be rovlded m nult all well pe The above MN eoknowedgemdtt number, wn'
5) The owner of the holes) shell maintain records of water quay tasting and submg this to the State Engineer upon west
6) A MONITORING HOLE CANNOT OE CONVERTED TO A PRODUCTION WATER WELL, except for puns of remealauon (recovery)
or as a permanent dewatettng systems Ft e
cord In accordance with the Water Wee won Rules and policies of the State
Engineer.
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER MS NOTICE WITHIN ga PAYS, PLEAss WRITE, - NO HOLES CONSTRUCTED' ON A
COPY OF THE ACHNOWLEDGPD NOTICE WITH THE FILE NUMBER AND PAX THE COPY TO THE DNISION OF WATER RESOURCES.
THIS ACKNOWLEDGEMENT OP NOTICE pool NOT INDICATE THAT WELL P1' ulrr(e ) CAN BE APPROVED,