WATER WELL REPORT2WATER WELL REPORT
Orrginnl S 1" copy -Ecology, 2"" copy -owner, 3"~ copy -driller
E' 0' 0' L ,0 ~ f'°},
Construction/Decommission ("x" in circle)
^ Construction
Decommission ORIGINALINST~ILLATIONNotice
of Intent Number
CURRENT
Notice of Intent No. AEO1997
Unique Ecology Wel] ID TagNo. NIA
Water Right Permit No. EXEMPT WELL
Property Owner Name FH1 LLC
Well Street Address 15036 5E 507 HWY
PROPOSED USE: m Domestic ^ Industrial ^ Municipal
^DeWater ^ Irrigation ^ Test Well ^ Other Cj~r YELM COllnty THURSTON
sw
n
TYPE OF WORK: Owner's number ofwell (ifmore than one) WELL 2
^ New well ^ Reconditioned Nlethnd : ^ Dug ^ Bored ^ Driven
^ Deepened ^ Cable m Rotary ^ Jetted a
Location SW 1/4-1/4 SE 1/4 Sec 25 Twn17N R1E
Q check
-" N,~,M ^ one
Lat/Lon S t, T Lat De Lat Min/Sec
~ g ~ > g
DIMENSIONS: Diameter of well ~_ inches, drilled ft.
Deptb of completed well 63 ft. Still REQUIRED) Long Deg Long Mjn/Sec
CONSTRUCTION DETAILS
Casing ^ Welded Diem. from ft. to R. Tax Parcel No. 21725130200
Installed: ^ Linerinstalled Diarn. from ft. to fl.
^ Threaded Diam. from $. to $. CONSTRUCTION OR DECOMMISSION PROCEDURE
Perforations: ^Yes ^No
Type ofperforator used Formation: Describe by color, charncter, size ofmateria] and shvcture, and the kind and
nature ofthe material in each stratum penetrated, with at leazt one entry for each change of
information. (USE ADDITIONAL SHEETS IF NECESSARY .
SIZE ofperfs in. by in. and no. ofperfs_from _ ft. to _ft. MATERIAL FROM TO
Screens: ^Yes ^ No ^ K-Pac Location DECOMMISSIONED IN ACCORDANCE WITH
h9anufacturer'sNarne WAC 173-160-381
Type Model No.
Diam
Slot size from ft
to R SECTION 1 5U6-SECTION B
.
.
.
Diem. Slot size from ft. to ft.
Gravel/Filter packed: ^Yes ^ No Sue of graveUsand
h4aterials placed from ft. to ft.
Surface Seal: ^Yes ^No To what depth? fr.
Material used in seal
Did any strata contain unusable water? ^Yes ^ No
Type of water? Depth of strata
Method of sealing strata off
PLT114P: Manufacturer's Name
Type: H.P.
WATER LEVELS: Land-surface elevation above mean sea level ft.
Static level 23 ft. below top ofwell Date 11113/06
Artesian pressure lbs. per square inch Date
Artesian water is controlled by
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(ca ,va
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c.)
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WELL TESTS
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raw
own
s amoun
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eve
owere
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eve
:
s
a
Was a
um
test tnade? ^Yes ^ No If yes
whom?
b
p
p
,
y
with ft
drawdown after hrs
Yield: Kal
/rein
.
.
.
.
Yield: Fal./rnin. with R. drawdown after hrs.
Yield: aal./rein. with ft. drawdown after hrs.
Recoveq~ date (rime taken as zero when pump turned oJ~ Grater level measured jrom ^~ell
lop to mater /ere/J
Time Water Level Time Water Level Time Water Level
Date of test
Bailer test gal./min. with ft. drawdown after hrs.
Airtest gal./min. with stem set at ft. for ]vs.
Artesian flow };.p.m. Date
Temperature of water Was a chemical analysis made? ^Yes ^ No
Start Date 11/13/06 Complet ed Date 11/13 !06
VI'ELL CONSTRUCTION CERTIFICATION: 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.
^ Driller ^Engineer ^Trainee Name (Print) RO RAY P YTHIAN Drilling Company ARCADIA DRILLING INC.
Driller/Engineer/Trainee Signature C~ Address PO BOX 1790
Driller or trainee License No. 2053 City, State, Zip SHELTON WA 98584
If TRAINEE, Contractor's
Drillcr's Licensed No. Regisvation No. ARCADDID98K1 Date 11/14/06
Driller's Signature
ECY 050-1-2U (Rev ;/OS) Ecology is an Equal Opportuniq~ Employer.