2011-01-20_HYDROLOGY - M1980244 (2)

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10/14/2010 06:34 7196893254 CCVGMC OWS41 D8/2000 Phone 4 Print Name: /73 ?,i , , 0 NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) 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. 8663561 —FAX: 303-866-3589 Location: -S 7 4 ✓ %, /V 'h, Section 1 7 Township /.51:3, N ITS, Range 61 OE pN, 6 Z M County Teru,igie Subdivision, Lot, Elk, FIg (aaoPticable) Site/Property Address Well Owner's Name, Address & Phone Ce -1 I4 / /// Wei G Landowner's Name w � Oc o , C� / Please check one end complete as indioeted including contact info: Wow Won Driller Ucensed in Colorado - Uc. No. ❑ Professional Engineer Registered in Colorado - Reg. No. ❑ Professional Geologist per CRS 341-201(3) riff Other -anyone directly employed by or under the supervision of a licensed driller, registered professional engineer or professional geologist /' Contact / Compeny / / !//��ON[ 4 t ✓ �e•e�l,�✓. 't� Addre$s City, State & Zip V/ cry', ‘ erft9 p PJ{ 7�9� ye Fax Fax 7 /,'rO P -2 Y Signature: ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE c FOR OFFICE USE ONLY I � - MH PROCESSED BY DIV. Z WD AS MD ) P pumping rag PAGE .. 02/03 RECG r N. GPS Location In UTM format (optional): Set GPS unit to We north, datum NAD83, and use meters for the distance units, OZone 12 or OZone 13, Easting Northing # of Monitoring Hole(s) to be constructed: 1 Estimated Depth . 75V FL, Aquifer Pu a of Monitoring Holes) 771 .4•0_4,410/17e0.„, .4•0_4,410/17e0.„, Anticipated Date of Construction: // /l /0 Date Notice Submitted: // A2 W (Must be at least 3 days prior to oonsction) DATE; ACKNCW EDGED Li- t•l° CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHAD, BE AVAILABLE AT THE DRILLING SITE. 1 Notice was rovided to the State Engineer at (east 3 days prior to construction of monitoring & observation hole(s). 2) Construction of the hole(s) must be completed within 9a days of the date notice was given to the State Engineer. Testing and/or shall not exosed a total of 200 hours unless prior written approval Is obtained from the State Engineer. Water diverted during testing MAIM be used for beneficial purposes. The owner of the holes) is responsible for obtaining permits) and complying with all rules and ulat pertaining ning to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. Minimum oonstructlon standards must be met or a variance wait obtained. Standard permit application and w report forms are found on the DWR website at r w ttaJ/ww Weil • Construction and Test Reports (GW13.31) must be completed for each hole drilled. The licensed oontractor or authorized individual 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 one (1) year after construction. An Abandonment Report (form GWS•9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's structure name, and owner's name and address must be provided on all wet permit eppiIcatfon(s), well construction and abandonment reports. 5) The owner of the hole(a) Shall maintain records of water quality testing and submit this date to the State Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remsdiation (recovery) or as a permanent dewatertng system, I1 constructed In accordance with the Water Well Construction Rules and policies of the State Engineer. 7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 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 SE APPROVED. (Use above space for labels or additional conditions es needed)