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NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />GWS -51 <br />08/2008 Please type or print legibly in black or blue ink / <br />COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821- DENVER -00-80203 <br />PHONE. 303 - 866 - 3581 -- -FAX: 303 - 866 -3589 <br />Well Owner's Name, Address & Phone CC-p y/, (, <br />P, 0. &x /9/ G % c,- co coce4 o <br />J <br />Landowner's Name CL v-t/ C DLO /7j,/ /,/h, (0, <br />Please check one and complete as indicated including contact info. <br />❑ Water Well Driller Licensed in Colorado — Lic. No. <br />❑ Professional Engineer Registered in Colorado — Reg No. <br />❑ Professional Geologist per CRS 34 -1- 201(3) <br />Other - anyone directly employed by or under the supervision of a licensed driller, <br />registered professional engineer or professional geologi <br />Contact ' Comp__.. / „ . 1� i / <br />Address <br />Print Name: <br />Signature: <br />Div. WD <br />1 0 , a, zr / 9/ <br />City, State & Zip (/ 2c..T - 0 2, ( 19 e"Dfrj <br />� <br />' <br />Phone 7/ 9-1,P- '9d Fax // / q 6 .1?) s-y <br />#49, . /49, -O <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />M H PROCESSED BY <br />BAS MD DATE ACKNOWLEDGED <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />Location: N14✓ 1 / //y/ Y<, Section , L / <br />Township /.� ❑N , Range 6 ❑EW, (r1D <br />County IEGGC/� <br />Subdivision, Lot, Blk, Flg (as applicable) <br />~/ <br />Site /Property Address % z (2 /e <br />, <br />GPS Location in UTM format (optional): <br />Set GPS unit to true north, datum NAD83, and use meters for <br />the distance units, ❑Zone 12 or ❑Zone 13. <br />Easting Northing <br /># of Monitoring Hole(s) to be constructed: <br />Estimated Depth 73 0 Ft., Aquifer <br />Purpose of Monitoring Hole(s) 770 4 E 4,e .)te,zb <br />_/2A ,"SD ✓C 612 /70/✓/ 7 //v4' 4 ✓2 <br />Anticipated Date of Construction: // <br />Date Notice Submitted: / / —Qcf /Q <br />(Must be at least 3 days prior to construction) <br />/ <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. <br />1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). <br />2) Construction of the hole(s) must be completed within 90 days of the date notice was given to the State Engineer. Testing and /or <br />pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted dunng testing <br />shall not be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining permit(s) and complying with at rules and <br />regulations pertaining to the discharge of fluids produced during testing. <br />3) All work must comply with the Water Well Construction Rules, 2 CCR 402 -2 Minimum construction standards must be met or a variance <br />obtained. Standard permit application and work report forms are found on the DWR website at http: / /www.INater.state.co.us. Well <br />Construction and Test Reports (GWS -31) must be completed for each hole drilled. The licensed contractor or authorized individual must <br />submit the completed forms to this office within 60 days of monitoring hole completion. <br />4) Unless a well permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment <br />Report (form GWS -9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's <br />structure name, and owner's name and address must be provided on all well permit application(s), well construction and abandonment reports. <br />5) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the State Engineer upon request <br />6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediation (recovery) <br />or as a permanent dewatering system, if constructed in accordance with the Water Well Construction Rules and policies of the State <br />Engineer. <br />7) IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS. PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A <br />COPY OF THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DIVISION OF WATER RESOURCES. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />JUse above space for labels or additional conditions as needed) <br />