20070235 Well Decommission and Transfer 12032013 RETURN ADDRESS
City of Yelm
Tami Merriman
105 Yelm Avenue West
Yelm, WA 98597
Document Title(s)
Well Decommission and Transfer
Reference Numbers(s) of related documents
Additional Reference #=s on page
Grantor(s) �Last,First aad Middle Initial)
Fairway Estates Mountain Terrace Builders, LLC
Kempinski, Michael, Manager
Additional grantors on page
Grantee(s) �Last,First and Middle Iaitial)
City of Yelm
Additional grantees on page
L@g81 D@SCY'1pt1011 (abbreviated form: i.e.lot,block,plat or section,township,raage,
quarter/quarter)
NW '/4 SE '/4 524, T17N, R1E
Additional legal is on page
Assessor's Property Tax Parcel/Account Number
21724420503
Additional parcel#=s on page
The Auditor/Recorder will rely on the information provided on this form. The staff will not read the
document to verify the accuracy or completeness of the indexing information provided herein.
I am requesting an emergency nonstandard recording for an additional fee as provided in RCW
36.18.010. I understand that the recording processing requirements may cover up or
otherwise obscure some part of the text of the original document.
� '�� �
. ' nature of Requesting Party
4370982 Pages: 3
12/03l2013 �4:00 PM Miscellaneous
Thurston County Washington
CITY OF YELM
�III h'i� �i�N�L M�;11u�:��� ���:f�3�l�'��� �I II I
wo�T�p� City of Yelm
�s ��
Well Decommission
and Transfer
YELM
wwsHihaTOw
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
SI7E 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 UWe attest that we are the legal owner�s)of the water right and/or well located above
� INNe 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
Q UWe 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 F 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�(`�i C�c,x���W1A��Sk i 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��tfat�l(4j�4their free and voluntary act and deed,for the uses and purposes therein mentioned.
���� M�RR� ����� � y _ `���,
Given ug�e�►���a��'��,a��is ���da of � 2
_ Q. � ,,,�7,, ��
�i o��'o��} ' y _ / ,�1
; .
i �v � • ' '��„ Nota Public in an for the State of Washington,
� N i, i0tt��� Q� residing at _%��1 �� � CT�
� !� ii� �
�'ii y�'��''',���9.r'�' �~s _ c�_
� � -� M commission ex ires: 1
�
��''� ,.w...,.���.
ri�t uK�c;,6 FIRST COPY-DEPT.Of ECOLOGY WATER WELL REPORT STAR7 CARD NO aeiesse
SECOND COPY-OWNER,THIRD COPY-DRILLER STATE OF WASHINGTON ��NIpUE WELL ID N!A
WAT'ER RIGHT PERMIT NO N!A
(1)OWNER NAME: MOUNTAIN TERRACE BUILDERS ADDRESS 14730 SR 50T YELM WA.98597
(2) LOCATION OF WELL: County THURSTON SE 1�4 NW 1!4 SEC 2d TWP 17N R 01E
(2a)STREET ADDRESS OF WELL(or nearest address): 15060 LONGMIRE RD SE VELM PARCEL 21724420503
i
(3)PROPOSED USE: ABANDONED � (10)WELI lOG OR OECOMMISSIONING PROCEDURE DESCRIPTION
(4)TYPE OF WORK: DECOMMISSIONINC� (
METHOD: PERFORATEJGROUT 1
� MATERIAL � FROM � TO
(5)DIMENSIONS Diameterofwell 6" inches.� EXISTINGWELL � i
Orilled feet. Deplh of completed well ft.� DIAMETER-6" � �
� DEPTH 95' � �
DECOMMISSIONED TO DOE REGS WAC 77J-160381 1A � �
PERFORATED CASING 4 CUTS PER ROW,ONE RONf PER I 1
(6)CONSTRUCTION DETAILS � FOOT FROM 95'UP TO 2'FROM GROUND LEVEL. � �
Casing instld: " Diam.From ft to R � TREMMIED NEAT CEMENT fROM BOTTOM Tp TOP. i �
Weided � " Diam.Ftom k, fo fl � CUT CASING APPROX 18"BELOW GRADE � �
Liner ❑ ' Diam.From R to H.� � '
Threaded ❑ �
1 I
� i I
I 1
Perforations: Yes �' No ❑ � 1 I
Type of perforator used MILLS KNIFE � ; i
Size of perforations 0.3 m. by 2 5 in � � '
372 perforations trom 2(t to 95' in.� � �
pertoraUons from R to in � ( �
perforetions Irom ft to in ( � �
� I i
1 I
Screens: Yes ❑ No 0 � � �
� I I
Manufacturer's Name: � � f
Type Model No � � �
Diam Slot size from ft to ft I � �
Diam Slot size from tt to ft.� � �
� I i
1 I
Gravel packed Yes ❑ No ❑ Size ot gravel? � � �
Gravel packed(rom R to ry � � �
! i
t 1
SuAace seal Yes ❑ No ❑ To what depth? It � � �
Matenal used�n seal i ; i
Did any slrata contain unusable water? Yes ❑ No0 ' '
Type of waler? Oepth o(Strata ft � � �
Method of seatUnp svata off � � �
� I I
I i
(7) PUMP: Manulacturels N�ma � � �
TYVe H P i I I
� i I
� I I
(8)WATER�EVELS Surtace elev above mean sea level ft � � �
StaSc level below top of well Date I I I
AAesian pressure Ibs.Per sq m. Oate � � �
Artesian pressure Is controlled by � I I
1 1
I
(9�WELL TESTS Pump tesl made? By Whom � Work Started 08/29/12 Completed 08/30l12
V�eIC qsl/min vnlh n arawdown aRar hre(
v�eid pw.im�n,„tn n dra.wown aner n�s WEL�CONSTRUCTOR CERTIFICATION:
vKa n,�.�,,;,,,„tn n ��,,,�a�,„,,,ne, n�,� I constructed andlor accept responsibility for construction of
Recoverydata: � this woll, and il3 compliance wilh all Wdshln9[Ofl W211 CO�SifUCt1011
Time Vtinr �vi Time Wtr Lvl Time wtr �vi. � standards. Materials used and the information reported
� above are true to my best knowledge and belief.
I
IName. RICHARDSON WELL DRILLING COMPANY INC.
Date of test: �Address, P.O.BOX 44427 TACOMA,WA 98444
3ailertest ysl!mm.nlh (1 drawdpwnafle� nra�
4irtest yallmin stem set at ry. tor n�,�(Signed) Lic No 2246
>rtesion tlow paUmin Date � �wea onrie�i
femperature of water Was chemical analysis made? �ContlactoPS Regislration No RICHAVY'�2108 DATE 8110/t2