20070235 Well Decommission and Transfer 09172013 �wo�T�A� City of Yelm
o ��
� Well Decommission
and Transfer
YELM
WABMINaTOw
PLEASE COMPLETE AND City of Yelm,Community Development Department
RETURN THIS FORM TO: 105 Yelm Ave.W, Yelm,WA 98597
DATE: June 10.2013
WELL NO WATER RIGHT NO:
TAX PARCEL NO: 21724420503
SITE ADDRESS: 15050 Longmire St SE
Yelm Wa 98597
PROPERTY OWNER: Mountain Terrace Builders LLC
OWNER ADDRESS: 14730 ST RT 507
Yelm WA 98597
THE FOLLOWING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE:
0 IIWe attest that we are the legal owner(s) of the water right and/or well located above
0 INVe are not aware of any changes,sales, or transfers of this water right to another person
0 The well has been decommissioned as required in Section 173-160-381 WAC
0 IIWe understand that based on the above information, all rights associated with the above
water right and/or well are hereby transferred to the City of Yelm.
IN WITNESS WHEREOF,this instrument has been executed the day and year first above-written.
BY BY
Grantor Grantor
STATE OF WASHINGTON )
) ss
COUNTY OF THURSTON )
On this day personally appeared before me to me known to be the individual(s)
described in and who executed the within and foregoing instrument,and acknowledged that she/he/they
signed the same as her/his/their free and voluntary act and deed,for the uses and purposes therein mentioned.
Given under my hand and seal this day of ,20
Notary Public in and for the State of Washington,
residing at
M commission ex ires:
ri�t uKtc;,s FIRST COPY-pEPT.OF ECOLOGY WATER WELL REPORT START CARD NO AE18538
SECOND COPY-OWMER,THIRD CQPY-DRILLER 57ATE',C1F WASH�NGTON 11NIQUE WEII ID N�A
WAT'ER RIGHT PERMIT NO NIA
(1) OWNER NAME: MOUNTAIN TERRACE BUILbERS ADDRESS 14T305R 507 YELM WA.98597
(2) LOCATION OF WEtI: County THURSTON SE 1/4 NW 1l4 SEC 24 TWP 17N R 01E
(2a) STREET ADDRESS of WEIL(or nearest address): 15050 LONGMIRE RD SE YE�M PARCEL 21724420503
t
(3) PROPOSED USE: ABANDONED � {10)WELL LOG OR OECOMMIS510NING PROCEDURE DESCRIPTION
(4)TYpE OF WORK: DECOMMISSIONING (
METHOD: PERFORATEIGROUT I
� MATERIAL � FROM � TO
(5) DIMENSIONS: Diameter of well 6" inches� EXISTING WELL � �
Drilled feet. Depth of completed well ft.� DIAMETER-6" � �
� 1 1
I OEPTH 95' � �
DECOMMIS510NE0 TO DOE REGS WAC 773-160381 1A � �
PERFORATED CASING 4 GUTS PER ROW,ONE R04V PER I �
(6) CONSTRUCT(ON pETAILS � FOOT FROM 95'UP TO 2'FROM GROUND LEVEL.' � (
Casing instld " Diam.From ft to ft � TREMMIED NEAT CEMENT FROM 80T70M T�TOP. � �
Sii�elded � " Dfam, From fi, to tt' CUT CASING APPROX 18"BELOW GRADE � �
Liner ❑ " Diam.From ft to h.� � I
Threaded ❑ � I �
I � �
1 �
Perforations: Yes � No ❑ I � �
1 �
Type oF perforator used MILLS KNIFE � � �
Sfze of perforations 0_3 in. by 2,5 in � � I
372 perforations 4rom p� to gg� �� i ( �
perforations tran R- to in � � i
perforations from ft to in I � �
� I 1
� � I
Screens: Yes ❑ Na 0 ' � �
Manufacturer's Name: ' � �
TYPe Model No � 1 1
�iam Slot size from R to ft I � �
Diam Slot size � �
from ft- to ft_1 � �
� I 1
I � �
Gravel packed Yes ❑ No � Size of gravei? I � �
Gravei paCked from ft- to k � � �
1 1
I i
Surface seal Yes ❑ No ❑ To what depth? ry I � �
MBteriai used in seal I � '
Oid any strata contain unusable water? Yes � No0 ( � �
Type of water9 Oepth of Strata h � ( (
Method of seailing s[rata off � � f
� 1 I
1 �
(7) PUMP; r.tanuracturers Name � i i
T1'� H P � I 1
� I 1
� I I
(8) WATER I.EVELS: Surface elev above mean sea Ievel ry, � � (
Static levei below top of weif Dafe � � (
AAesian pressure Ibs.Per sq,in. Date 1 � �
Artesian pressure 1s controiled by 1 ( �
� I �
I �
(9) WE�[.TESTS Pump test made? 8 Whom �
v�eid y I Work Started 08/29/12 Com leted.
qai/mm vai�h fl drawdown aker }��y( P OS/30/12
Y'�� e�/m�^'���n n drawctown aner nrs WELI.CONSTRUCTOR CERTIFICATION:
Y,�w �e�,m;,,�Fn n u��waQw„a„g, n.�� I constructed andtor accept responsibility for construction of
Recovery data: � this woll, and ita compliance with aII WaShlltg[0�WE;II CO�StfUCtt0l1
Time Wtr �vi. Time wtr l.vl. T�me wtr �vi. � standards. Materials used and the information reported
� above are true to my best knowledge and belief.
I
1Name, RICHARDSON WE�I.DRILLING C4MPANY INC.
Date of test �Address, P.O.BOx 44427 TACOMA,WA 98d44
3ailer test gal.?mm with ft c7rawaown aryer nn(
>irtest gaUmin stem set at ft. for n�s�(Signed)
artesion tiow gaVmin Date Lic No. 2246
femperature of water Was chemicai anal sis made? � [wen on�ic�j
Y �Contractor's Registration No RICHAW"32108 QATE 8130/t2