WATER WELL REPORT1~ WATER WELL REPORT
Onginal & 1" copy- Ecology, 2"'~ copy-owneq 3"~ copy-driller
E~l~O~L~~O~f,~1'
Construction/Decommission ("x" in circle)
^ Construction
~ Decommission ORIGINAL INSTALLATION Notice
oflntent Nalmber
CURRENT
Notice of Intent No. AEO1986
Unidue Ecology Well ID Tag No. N/A
Water Right Permit No. EXEMPT WELL
Property Owner Name FHi LLC
Well Street Address 1536 SE 5D7 HWY
PROPOSED USE: m Domestic ^ Industrial ^ Municipal
^ DeWater ^ Irrigation ^ Test Wetl ^ Other
City YELM CDllnty THURSTON
E
"7
TYPE OF WORK: Owner's number ofwell (if more than one)
^ New well ^ Reconditioned Method : ^ Dug ^ Bored ^ Driven
^ Deepened ^ Cable m Rotary ^ Jetted Location SW 1/4-I/4 SE I/4 Sec 25 Twn17N R1E
check
or
^
WWM ^ one
(Lat/Long (s, t, r Lat Deg Lat Min/Sec
DIMENSIONS: Dianreterofwell~_ inches, drilled ft.
Depth of wtnpleted well 139 ft. Still REQUIRED) Long Deg Long Min/Sec
CONSTRUCTION DETAILS
Casing ^ Welded Diam. from ft. to ft. Tax Parcel No. 21725130200
Installed: ^ Linerinstalled "Diam. from ft. to ft.
^ Threaded "Diam. from ft. to ft. CONSTRUCTION OR DECOMMISSION PROCEDURE
Perforations: ^Yes ^No
Type ofperforatorused Formation: Describe by color, chazacter, size ofmateria] and stmcture, and the kind and
nature ofthe material in each stratum penetrated, with at least one entry for each change of
information. U5E ADDITIONAL SHEETS IF NECE55ARY.
SIZE ofperfs in. by in. and no. of perfs_from _ ft. to _ft. MATERIAL FROM TO
Screens: ^Yes ^No ^K-Pac Location DECOMMISSIONED IN ACCORDANCE WITH
Manufacturer's Name WAC 173-160-381
Type Model No.
Diam
Slot size from ft
to ft SECTION 1 SUB-SECTION B
.
.
.
Diam. Slot size from ft. to ft.
GraveVFilter packed: ^Yes ^ No ^ Size of gravel/sand
Materials placed from fr. to ft.
Surface Seal: QYes ^No To what depth? ft.
Material used in seal
Did any strafe contain unusable water? ^Yes ^ No
Type ofwater? Depth of strata
Method of scaling strata off
FUMP: ivlanufacturer';Nama
Type: H.P.
WATER LEVELS: Land-surface elevation above mean sea ]eve] $.
Static level 61 fr. below top ofwell Date 11 /10/O6
Artesian pressure lbs. per square inch Date
Artesian water is controlled by
valve
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WELL TESTS
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Was a
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test made? ^Yes ^ No If
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Yield: Pel.lmin. with ft. drawdown after hrs.
Yield: Pal.hnin. with ft. drawdown after hrs. '
Yield: Pal./min. with ft. drawdown after hrs.
Recore;3~ data (time taken as zero when pump nrrned olp (irarer level measured from well
mp ro motet level)
Time Water Level Time Water Level Time Water Level
Date of test
Bailer test gal./rnin. with ft. drawdown after hrs.
Airtest gal./min. with stem set at fl. for hrs.
Artesian flow P.p.rn. Date
Temperature of water Was a chemical analysis made? ^Yes ^ No
Start Date 11/10/06 Complet ed Date 11/10 /06
~~'ELL CONSTRUCTION CERTIrICATION: I constructed and/or accept responsibility for construction of this well, and its compliance with all
Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief.
IDDriller ^Engineer ^Trainee Natne(Prin~) R ERA P YTHIAN Drilling Company ARCADIA DRILLING INC.
Driller/EngineerJTrainee Signature /s ~s / Address PO BOX 1790
Driller or nainee License No. 2053 City, State; Zip SHELTON WA 98584
if TRAINEE, Contractor's
Driller's Licensed No. Registration No. ARCADDI096K1 Date 11/13/06
Driller's Signature
EC1' U50-1-2U (Rev 3105) Ecoloay is an Equal Opportunip~ Employer.