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 -12 -11 11:42 FROM -Colo Div of Water Resources
Landowner's Name _CGy�✓ r,c, 0 C�
Please check one end complete as Indicated Enduding contact Into:
❑ Water Well DrlOor Licensed In Colorado, Lac. No.
o Professional Engineer Registered to Colorsdo.. Reg. No.
Protessfortel Geologist per CRS 34.1.201(3)
M aimed Madly employed ,n p by or under the sup an of a licensed driller.
Contact / Comj /! G
da7 /y
Address / r .h
qty, State & Zip 4 CO qO e6
Phone 7/ 9. 09-y ye Fax 2/9- ed' �- .�a2s�1
Print Name:
Signature:
NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S)
Please type or print legibly In btsdc or blue Ink _
COLORADO ONISION OF WATER RESOURCES-1313 SHRRMAN ST-fq �,D (WW— ~ ��
PH ONE 30 3.886.3881 —. FAX: [phone] X203
is Name, Address & Phone (r� !� O / % (
KtSyo
1
..4./►/On/
ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE
FOR OFFICE USE Or&
- MH PROCESSED SY
[phone] T -572 P 002/002 F -830
Location: % 4/6 y Section 2/
Township ON 3e, Rentle DE 00,_6541
County
7F
Subdivlalon, Lot, ark, Rg (a��lcable)
Address ,r Dvvey if0 �.,�
GPS Location In UTM format (optional):
Set GPS unit to true north, datum NADE3, and use meters for
the distance units. QZona 12 or Mono 13.
Fasting Northam
ft of Monitoring Hole(e) to be constructed:
Estimated Depth Qjrt Aquifer
Purpose of Monitoring mss) r s Dve•to 4 %p7 -
AMlcIpated Data of Conatrudton: 0/—/7—//
Date Nofioe Submitted:
� 41- -1/
1u' be at bast 3 days prix to cone uapon)
414
Div. WD � '
Sas M7 DATEACKNOVVL®OED l - 1 ti -It
CONDITIONS OF MONITORING HOLE ACKNOWLEDt EMENT
A COPY OPINE WRIT SN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SOTE.
1) Notice was provided to its State Engineer at least 3 days prior to constmcllon of ItiOnitoring & observation Weis).
2) Construction of the holes) must be completed within Ikea of tits data notice was given to tha sate Engineer. Testing and/or
Max be used for benencial
of 200 tours unless prior wittiest approval Is obtained from the Stets Engineer. Water diverted during testing
Windom purposes, The owner of the hola(a) Is responsible for obtaining pam((a) and y with an rules and
p&tali*iS b dw dlsd'antge of fluids produced during g•
3) All work must comply with the Water Wall Construction Rules, 2 CCR , G2.2. Minimum construction standards must be met or a variance
obtained. Standard permit application and work report fry are found on the DWR website at
) must s hole(e)
80 Construetjan and Test Reports Waal) Met be completed for each hole drilled, , The licensed WWI
the completed forms to this of ice within 80 corabtertor or authorized hxtividual must
4 ) finless a well permit A ht the la ohAe�ed, hole (e � monito hole compietbn.
Report Mi (foram G M meat submitted ot plugged and sealed within one (1) year der construction. An Abandonment
days of plugging & sealing. The above MH acknowledgement number, owner's
structure name, and (wnees Hanle and address Must be Provided on all wail permit application(s), wsf construction and abandonment reports.
5) The owner of the hoh(s) shall maintain records of water quality testing and submit lids data to the Stab Engineer upon request.
6) A MONITOKING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remadiatlon (rso
or as >W pernmanont dewatering gym, If constructed in accordance with the Water Wall Construction Rules and policies of the State
Engineer.
7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN tre DAYS, PLBAmE WRI7L, "NO HOLES CONSTRUCTED" ON
Copy OP THE ACKNOWLEDGED NOTICE MIME FILE tIUMBIIR AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES.
THJO ACKNOWLEDGEMENT OP NOTICE noes NoT INDICATE, THAT WELL PERMIT(S) CAN BE APPROVED.
Nee above space for fabele or additional conditions es needed)