2011-01-20_HYDROLOGY - M1980244 (2)

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11 -09 -10 08:06 FROM -Colo Div of Water Resources ows. i NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) omen Please type or print legibly in black or bk e Ink / WV- 07 COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST-RM 821- DENVER -CO.907A3 PHONE 303- 888 - 3581 --FAX; 303.666.3589 Well Owner's Name, Address & Phone Ceie/4 ,,�"42 CP, 40. Z'Qx /9 /_, Vic-772.e. e. CO ear o 1- andowner's Name CL. I (/ 4 _� /Nj,14' Co. Please check one and complete es Indicated including contact Info: ❑ Water Well Driller Uoensed in Colorado — Uc. No. ❑ Professional Engineer Registered in Colorado — Rag. No. ❑ Profeselonai Geologist per CRS 34-1-201(3) As Other - anyone directly employed by or under the suporvlsion of a licensed driller, registered professional engineer or prr�o�ffe5slonel geo Contact / Company / 9,R,c V Novi !GeVI/ �oz-0 /7446 6, Address AO, dot. / 9/ City, State & Zlp (/C1) et Co tf otb� Phone 7/ 9^1 e/ ~ yOVQ Fax 7/ l - �d / • .��y lipt sly, Z WD l2 ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE USE ONLY BAS MD - MH PROCESSED BY +3038663589 T - 409 P 001/002 F - 303 Location; Nl+✓ '/e ,'VI" A, section Township /S Range 6 ❑E►►, G''M County �� Subdivision, Lot, Blk, Fig (ae applicable) .e Site/Pp Address e:14 �ov w GPS Location In UTM format (optional): Set GPS unit to true north, datum NAD83, and use meters for the distance units. ❑Zone 12 or ❑Zone 13. Fasting Northing 0 of Monitoring Hole(s) to be constructed: / Estimated Depth 73 O Ft, Aquifer Purpose of Monitoring Hole(s) 77o 4 E (p' Anticipated Date of Construction: /1 /,S =/O Date Notice Submitted: (Must be et least 3 days prior to oonstruotlan) DATE ACKNOWLEDGED 11 _i +t0 CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRiTTEN NOTICE OR ACKNOWLEDGEMENT SHALL, BE AVAILABLE AT THE DRILLING SITE. 1) Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). 2) Construction of the hole(e) must be 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 shalt not be used for beneficial purposes. The owner of the hole(e) le responsible for obtaining permlt(s) and complying wteh all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Waii Construction Rules, 2 CCR 402-2. Minimum oonstruotion standards must be met or a variance obtained. Standard permit application and work report forms are found on the DWR webslte at jitts://wilwAvater.stutc.co.us. Well Construction and Test Reports (GWS -31) must be completed for each hole drilled. The licensed contractor or authorized Individual must submit the completed forms to this oMoe within 60 days of monitoring hole completion. 4) Unless a wall permit is obtained, the hole(s) must be plugged and sealed within one (1) year after construction. An Abandonment Report (form GWS-a) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's structure name, and owners name and address muss be provided on all well permit appllcation(e), well construction end abandonment reports. 6) The owner of the hole(s) shall maintain records of water quality testing and submit this data to the Steeto Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remedtaton (recovery) or as a permanent dawatsring system, If constructed in accordance with the Water Well Construction Rules and policies of the State Engineer. 7) iF HOLES WILL NOT BE CONSTRUCTiD UNDER THIS NOTICE WITHIN 9D DAYS, PLEASE WRi'CE, "NO HOLES CONSTRUCTED" ON A COPY OF THE ACKNOWLEDGED NOTICE WiTH THE FiLE NUMBER ANP FAX THE COPY TO THE DMS!ON OF WATER RESOURCES. THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WEU• PERMIT(E) CAN BE APPROVED. (Use above apace for labels or additional oonditions as needed)