2011-07-25_REVISION - M1977215 - Laserfiche WebLink

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RECE V (� I 1 - `ZP' �- (G JUL 28 2011 � Division of Reclamation, cws•sl NOTICE OF INTENT TO CONSTRUCT 6 f HOLE (S) l" 0612011 Please type a print legibly in black or blue ink Signature 9 COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821- DENVER -CO -80203 PHONE: 303 - 868.3581- -FAX: 303.866- 3589 1 Location: dw % NW Y.. Section 26 Township V COOS, Range / OE Bfiv.MiPm County Maw" 1 Subdivision, Lot. Sic, Fig (as appicable) Well Owner's Name, Address S Phone 1 .b i6 swot. .7„,c Pis b„ feio, C,eede, CO. 01/30 C7if) 6s - meg) Landowner's Name .Pews /d itour.gis Please check one and complete as indicated 'including contact info: cater Well Driller Licensed In Colorado — Lie. No. 1393 ❑ Professional Engineer Registered in Colorado — Reg. No. 0 Professional Geologist per CRS 34.1- 201(3) ❑ Other - anyone dracy empoyed by cr under the supervision of a Scented dri0er, registered prclesaionel engineer or professional geologist :� Contact /Company / eers.wL . /fry Rr Address /f 6 efA.n4y tC /2-1' City, State & Zip 41wAws:A, Co. 0/ /D/ Phone (7i9) 589- SVG J 7 Fax Print Name: A kJ. MO ACKNOWLEDGEMENT FROM STATE ENGINEERS OFFICE FOR OFFICE USE ONLY - MH PROCESSED BY Div. WD BAS MD DATE ACKNOWLEDGED 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 prlor to construction of monitorhag & observation hole(s). 2) Construction of the hots(s) must be completed within 90 days of the data 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 kom the State Engineer. Water diverted during testing ;JAM be used for beneficial purposes. The owner of the hole(s) is responsible for obtaining permtt(s) and oornplying with all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402.1 Minimum construction standards must be met or a variance obtained. Standard permit application and work report forams are found on the OWR webslte at httn:l /o w n.n*Ier,statc ce,es. Weti Construction and Test Reports (GWS - 31) must be completed for each hale drilled. The licensed contractor 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 well perms application(s), well construction and abandonment reports, 5) The owner of the holes) shall maintain records of water quality testing and Submit this data to the State Engineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WELL, except for purposes of remediation (recovery) or as a permanent dewatering system, if 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 BE APPROVED. ECEDVE DURANGO FIELD OFFICE DIVISION OF RECLAMATION, MINING AND SAFETY Site/Property Address GPS Location In UTM format (optional): Set GPS unit to true north, datum NAD83, and use meters for the distance units, OZone 12 or Worm 13. Easting / /S 7 ZQ Northing //067L /3 aft of Monitoring Hole(s) to be constructed: / Estimated Depth rip Ft., Aquifer iirtra. r4gs*r' Purpose of Monitoring Hole(s) Aid4tr /ere l 1 ,..m A • Anticipated Date of Construction: .1 Zx {,J Jell � Date Notice Submitted: VAsl' /1 // (Must be at lea days paw to construction) (Use above space for labels or additional conditions as needed)