Free Microsoft Word - Document1 - Colorado

GWS-62 02/2005

NOTICE OF INTENT TO CONSTRUCT DEWATERING WELL(S)
Please type or print legibly in black or blue ink Location: Township N ¼ S, Range ¼, Section E W, PM

Well Owner's Name Landowner's Name Name & Mailing Address of Authorized Individual or Driller: Name Please check one and complete as indicated: Driller Licensed in Colorado ­ Lic. No. Professional Engineer Registered in Colorado ­ Reg. No. Professional Geologist per CRS 34-1-201(3) Company Address City, State & Zip Phone Fax

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.

Easting

Northing

# of Dewatering Well(s) to be constructed: Estimated Depth Purpose of dewatering Anticipated Date of Construction: Period of Use: Print Name: Signature: / / to / / / / Ft., Aquifer

ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE USE ONLY ______________________________________

- DW

PROCESSED BY ______________________________ DATE ACKNOWLEDGED __________________________ GROUND ELEV _____________ USGS MAP # _______

DIV. ________ CNTY ___________ WD ___________ BAS ________ MD ____________

CONDITIONS OF DEWATERING WELL 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 the dewatering well(s). 2) Construction of the well(s) must be completed within 90 days of the date notice was given to the State Engineer. 3) Diversion of water through the dewatering well(s) is limited to temporary dewatering purposes for construction only. Water diverted from the dewatering well(s) shall not be used for beneficial purposes and all ground water pumped must be discharged to the stream system without consumptive use, including evaporative losses. The owner of the well(s) is responsible for obtaining permit(s) and complying with all rules and regulations pertaining to the discharge of fluids produced. 4) All work must comply with the Water Well Construction Rules, 2 CCR 402-2. 5) Well Construction and Test Report(s) (GWS-31) must be submitted to this office by the licensed contractor or authorized individual within 60 days of the completion of the work. 6) Unless a well permit is obtained, the well(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. Note that a variance from the Water Well Construction Rules will be necessary to obtain a well permit if minimum construction standards for water wells (Rule 10) are not met. 7) The owner of the well(s) should maintain records of water quality testing and submit this data to the State Engineer upon request. 8) The above dewatering well (DW) number, owner's structure name, and well owner's name and address must be provided on all well permit application(s), well construction and abandonment reports. 9) THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. Additional Conditions ____________________________________________________________________________________________

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COLORADO DIVISION OF WATER RESOURCES-1313 SHERMAN ST-RM 821-DENVER-CO 80203 303-866-3581/FAX 303-866-3589