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Home My WebLink AboutResolution - 2009-R0261 - Contract - Talon_LPE - Demolition And Plugging Of Water Wells And Well Houses - 07_08_2009Resolution No. 2009-RO261 July 8, 2009 Item No. 5.25 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute a two job order contracts and any associated documents with Talon/LPE of Amarillo, Texas, for demolition and plugging of five obsolete water wells and the accompanying concrete and brick well houses (#09-050-F-050-NJPA) and for the plugging and abandonment of fifteen obsolete water wells (#09-051-F-051-NJPA) per National Joint Powers Alliance (NJPA) indefinite quantities construction contracts, which contracts and any associated documents are attached hereto as Exhibit A and made a part hereof for all intents and purposes. Passed by the City Council this 8th day of July 52009 ATTEST: el --I 'I' TOM MARTIN, MAYOR Rebe a Garza, City Secretary AS TO CO Aubrey Spear, P,#.; Direct9f of Water Utilities APPROVED AS TO FORM: Attorney DDres/ TaionLPE-NJPACon09 W aterRes June 24, 2009 Resolution No. 2009-RO261 City of Lubbock Job Order This Job Order is governed by all terms and conditions of the Contract referenced below which is hereby incorporated by reference. Owner: Wesley Everett, Director of Facilities Management for Water Production Well Plugging NJPA Contract No.: TX04-061908-TAL, National Joint Powers Alliance (NJPA), Indefinite Quantity Construction Contract. Contract Job Order no.: 09-050-F-050-NJPA Contractor: Talon/LPE. Date of Contract: September 25, 2008 Job Order Date: June 24, 2009 Project Architect for this Job Order: List name, phone number and firm name of Architect contracted for this project. NLA Summary and Description of Statement of Work attached hereto: Demolish and Plug Five Obsolete Water Wells and Accompanying Concrete and Brick Well Houses. Talon Job Order Number: 009202.00 hereto attached. Value of pre -priced work: $ 50,840.64 Value of non -pre -priced work: 00.00 Payment and Performance Bonds: $2,675.82 Insurance Requirements per Exhibit A, attached. Total Fixed Price stipulated sum for this Job Order (".lob Order Sum"): $ 53,516.46 Notice to Proceed Date for this Job Order: To be issued after City Council approval Expected Completion Date for this Job Order: To be determined after City Council approval Liquidated Damages (if different than as set forth in Agreement): $25 per day CONTRACTOR: CITY OF LUBBOCK.. TEXAS (OWNER): Talon/LPE. By: PRINTED NAME: BRIDGER HOWARD TITLE: PROJECT MANAGER COMPLETE ADDRESS: Company Talon/LPE Address 921 N. Bivins Street City, State, Zip Amarillo, TX 79107 ATTEST: Corporate Secretary By.ify.z MAYOR ATTEST: City kcreiary APPROVED AS TO CONTENT: 11`;ti`.. Q:l PurchaseTublic Works Contract ing'iob Order Contracts 612412009 "EXHIBIT A" Resolution No. 2009-R0261 ACO-W. CERTIFICATE OF LIABILITY INSURANCE DATE 12)2411`08 .YYYYy 12124108 : PRODUCER I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hlib Ftogal & Hobbs of Amarillo ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE, 1800 Washington, Suite 400 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, POBox1149 Amarillo, TX 79105.1149 INSURERS AFFORDING COVERAGE i NAIC 0 INSURED !NELRER A American Intl Specialty 67763 Talon/1-PE, Ltd. ! !N5cREA B. Texas Mutual Insurance Company 22945� 921 N. Blvins Street tiSRLR c America First Insurance 12696 Amarillo, TX 79107 RERD, f INSURER E. ! rnvrPAGFS THE POLZiES OF INSURANCE LISTED BLLCW HAVE BEEN ISSUED TO THE INSURED NAI.IEO ABOVE FOR THE POLICY PERIOD INDICATED, NOTW(THSTA`iD6NC- ANY REOUIREMENT, TERM OR CONDIT01V OF ANY CONTRACTOR OTHER DOCUMENT 'T11TH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED :R :IA',, PERTAIN. THE INSURANCE AFFORDED BY I HE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONCiTiONS OF SUCH PCLI DIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEC BY PA!D CLAIMS. fA LTR S TYPE OF INSURANCE PDLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL L4481UTY 3Xj,.COMMERCIAL GENERAL LIABILITY PROP14225734 12I31108 12/31/09 EACH CCCuRR£NCE S1 000 000 CAP E EE TO RENTED ` , $300 000 I ---T_"- CLAIMS MACE CG',',UR X I PD Ded:10,000 NE EXP ;Any cne person; $25 OUD PFRSCNAL a ADV INA RY $1 000 00U ' GENES PAL AGGREGATE $2 OOP OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP!OP AGG S2,000,000 POLICY PR4 LOC C AUTOMOBILE X UABILMY ANY AUTO BA8369955 12/31/08 12131/09 I COMBINED SINGLE LIMB tEa, xddent) $1 ,000,000 BODILY 1NIURY iPar person} --_ $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (P®re ddenq S X X HIREDAUTOS NON-OWNEO AUTOS ! I j PROPERTY DAMAGE f P9r pcweltt) S GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN Ea• ACC S 3 ANY AUTO S 1 AUTO ONLY, AGG A EXCESSIIIMBRELLA LIABILITY X OCCUR F—ICLAIMS MADE PROU14225993 12/31/08 12/31109 EACH OCCURRENCE $9 000 000 AGGREGATE $9 000 000 S I g DEDUCTIBLE $ X RETENTION $10000 B WaRI(ERS cDISPENBATI®N AND TSFOOOI155583 12131/08 12/31/09 We srATu on-I- FR B EMPLOYERS` LIANUTY ANY PROPRIETORIPARTNERIE7f);CUTiVE E.L. EACH ACCIDENT 51,000,000 E.L. DISEASE- EA EMPLOYEE S11000,000 CFFICERRdEMBER EXCLUDE01 If yes, dea"be wMar SPECIAL PROVISIONS belo El DISEASE-FOLICY L:MkT $1,000 000 OTRIR DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT ; SPECIAL PROVISIONS It Is hereby understood and agreed that the certificate holder is an additional insured on the general liability and the general liability Is primary. A waiver of subrogation applies on the general liability, automobile and workers compensation coverage. The general liability does (See Attached Descriptlans) r— City of Lubbock 1625 13th Street Lubbock, TX 79414 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSU{NG INSURER WILL ENDEAVOR TO MAIL 11`1 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRES$NTATIVE At;URU 25 (20011100) 1 of 3 #M71243 LGM o ACORD CORPORATION 1988 „E?B1B1T A” IMPORTANT If the certificate holder is an ADD3TIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemeni(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it afTirmafively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACURU 25-5 (2001105) 2 of 3 #M71243 "EXHIBIT A" AMS 25.3 (2001/08) 3 of 3 #M79243 j'_j Q Pj Contractor's Cost Proposal Detail - CSI Date: 06/22/2009 Basic Proict Information Job Order Number: 009202.00 Job Order Name: Pump house Demo Contractor: Talon/LPE Proposal Name: Pump house Demo and Plug Proposal Value: $53,516.46 Brief Scope: Pump House Demolition Sect horn Mod. UOM Decription Line Total Section 01-General Requirements 1 01352 0044 HR Investigating Engineer Or Specialty Consultant,Ncte: For special investigating 491.00 reguiremertts or services outside required architectural and engineering services Quantity Unit Price factor Total Installation 5.00 x 80.00 x 1.2275 491,00 NESHAP Certified Individual On Site During Demolitions 2 01590 0210 WK 36" Wde, 1/8 CY Bobcat, With Full -Time Operator 1,573.50 Quantity Unit Price Factor Total Installation 1.00 x 1.281.87 x 1.2275 = 1.573.50 3 01590 0754 WK 1-112 Ton Flat Bad Truck, 4 x 2, With Full -Time Truck DriverNote: Includes hydraulic 2.257,46 4libed. Quantity Unit Prim Factor Total Installation 1.90 x 1,839.07 x 1.2275 = 2,257.46 4 01590 0764 WK 314 Ton Light Duty Truck, 4 x 4 Crew PickupNots: With full-time truck driver 2,172.16 Quantity Unit Prim Factor Total Installation 1.00 x 1,769.58 x 1.2275 = 2,172.16 5 01590 0817 EA Bobcat DeliverylMob/DemobNote: Use for bobcat or similar sized equipment Includes 619.15 deRmy fee, delivery, set-up and retum. Quantity Unit Prim Factor Total Installation 5.00 x 100.88 x 1.2275 = 619.15 Assist with well abandonment 6 01590 0818 EA Backhoe, Dozer Or Roller Up To 250 HP DeliverylMob/DemobNote: Use for backhoe, 411.40 dozer, roller, loader, excavator or similar sized equipment. Includes delivery fee, delivery, set-up and return. Quantity Unit Price factor Total Installation 1.00 x 335.15 x 1.2275 = 411,40 7 01590 0818 EA Backhoe, Dozer Or Roller Up To 250 HP DeliverylMoblDemobNote: Use for backhoe, 411.40 dozer, roller, loader, excavator or similar sized equipment. Includes delivery fee, delivery, bat -up and return. Quantity Unit Price Factor Total Installation 1.00 x 335.15 x 1.2275 = 411.40 8 01590 0818 EA Backhoe, Dozer Or Roller Up To 250 HP Delivery/Mob/DemobNote: Use for backhoe, 411.40 dozer, roller, loader, excavator or similar sized equipment. Includes delivery fee, delivery, set M and return. Quantity Unit Prim Factor Total Installation 1.00 x 335.15 x 1.2275 = 411.40 22 _une 2009 Page 1 of 4 EZIQC Job Order Package 009202.00 1 sett. Item Mod. UOM Decription Line Total 9 01590 0810 EA Backhoe, Dozer Or Roller Up To 250 HP DeliverylMablDemabNote: Use for backhoe, 411.40 dozer, roller, loader, excavator or similar sized equipment. Includes delivery fee, del oat and Q Unit Price Factor Total Installation 1.00 x 335,15 x 1,2275 = 411.40 10 01590 0810 EA Backhoe, Dozer Or Roller Up To 250 HP Deiivery/MoblDemobNote: Use for backhoe, 411.40 dozer, roller, loader, excavator or similar sized equipment Includes delivery fee, detivery, setup and 2ej2m. Qua" Unit Price Factor TOW Installation 1.00 x 335,15 x 1.2275 = 411.40 Subtotal for 01-General Requirements $9,170.27 Section 02-SiteWork 11 02111 0015 CCF Demo Masonry Building With BultdozerlExcavator Remove Building 431.47 Quantity Unit Price Factor Total Installation 25.00 x 14,06 x 1.2275 = 431.47 12 02M0D 0015 0004 For Quantities Up To 500, Add 129.50 Quantity Unit Price Factor Total Installation 25.00 x 4.22 x 1.2275 = 129.50 13 02111 0015 CCF Demo Masonry Building With BulldozerlExcavator Remove Building 258.88 Quantity Unit Price Factor Total Installation 15.00 x 14.06 x 1.2276 = 258.88 14 02111 0015 CCF Demo Masonry Building With BulldozerlExcavator Remove Building 258.88 Quantity Unit Price Factor Total Installation 15.00 x 14.06 x 1.2275 = 258.88 15 02111 0015 CCF Demo Masonry Building With BulldozerlExcavator Remove Building 258.00 Quantity Unit Price Factor Total Installation 15.00 x 14,06 x 1.2276 = 258.88 16 02111 0015 CCF Demo Masonry Building With BulldozerlExcavator Remove Building 258.88 Quantity Unit Price Factor Total Installation 15.00 x 14.06 x 1.2275 = 258.88 17 02112 0088 CIF Demo Reinforced Concrete Building Foundation 1,241.00 Quantity Unit Price Factor Total Installation 300.00 x 3.37 x 1.2275 = 1,241.00 18 02112 0088 CIF Demo Reinforced Concrete Building Foundation 1.241.00 Quantity Unit Prke Factor Total Installation 300.00 x 3.37 x 1.2275 = 1,241.00 19 02112 0088 CIF Demo Reinforced Concrete Building Foundation 1,241.00 Quantity Unit Price Factor Total Installation 300.00 x 3.37 x 1.2275 = 1,241.00 20 02112 0088 CIF Demo Reinforced Concrete Building Foundation 1,241.00 Quantity Unit Price Factor Total Installation 300.00 x 3.37 x 1.2275 = 1,241.00 21 02112 0088 CIF Demo Reinforced Concrete Building Foundation 1,241.00 Quantity Unit Price Factor Total Installation 300.00 x 3.37 x 1.2275 = 1,241.00 22 02115 0040 HR Hourly Office Work For Both For Reports Required For EPA. Includes Title Searches, 558.02 Well Survey Data, Drawing Site Drawings, Filing preliminary work with EPA for feedback, Prepare on CAP -A and CAP-B plans, etc. Hours not to be used in association with odwi asks performiad. Quantityl Unit Price Factor Total Installation 10.00 x 45.46 x 1.2275 = 558.02 22 June 2009 Page 2 of 4 EMOC Job 0r+dW Padtap OOD=0O 1 Sect Item Mod. Will Decripdon Line Total 23 02119 0014 CYM Hauling On Paved Roads, First 15 Miles 154.67 Quantity Unit Price Factor Total Installation 280.00 x 0.45 x 11275 = 154.67 24 02119 0014 CYM Hauling On Paved Roads, First 15 Miles 154.67 Quantity Unit Price Factor Total Installation 280,00 x 0.45 x 1.2275 = 154.67 25 02119 0014 CYM Hauling On Paved Roads, First 15 Miles 154,67 Quantity Unit Price Factor Total Installation 280.00 x 0,45 x 1.2275 = 154.67 26 02119 0014 CYM Hauling On Paved Roads, First 15 Miles 154.67 Quantity Unit Pries Factor Total Installation 280.00 x 0.45 x 1.2275 ' 154.87 27 02119 0014 CYM Hauling On Paved Roads, First 15 Miles 154.67 Quantity Unit Price Factor Total Installation 280.00 x 0.45 x 1.2275 = 154.67 28 02210 0018 CY Backfilling Around Building Foundations And Other Structures by Hydraulic Excavator, 39.77 Backhoe,Loader Quantity Unit Price Factor Total Installation 15.00 x 2.16 x 1.2275 = 39.77 29 02210 0018 CY Backfilling Around Building Foundations And Other Structures by Hydraulic Excavator, 39.77 Backhoe Loader Quantity Unit Price Factor Tote) Installation 15.00 x 2.16 x 1.2275 = 39.77 30 02210 0018 CY Backfilling Around Building Foundations And Other Structures by Hydraulic Excavator, 39.77 Backhoe, Loader Quantity UnitPrice Factor Total Installation 15.00 x 2.16 x 1.2275 = 39.77 31 02MOD 0018 0087 For Quantities Up To 20 (Up To 15 M3), Add 26.51 Quantity Unit Price Factor Total Installation 10.00 x 2.16 x 1.2275 = 26.51 32 02210 0018 CY Backfilling Around Building Foundations And Other Structures by Hydraulic Excavator, 26.51 Badchoe, Loader Quantity Unit Price Factor Total Installation 10.00 x 2.16 x 1.2275 = 26.51 33 02210 0016 CY Backfilling Around Building Foundations And Other Structures by Hydraulic Excavator, 39.77 Backhoe,Loader Quantity Unit Price Factor Total Installation 15.00 x 2.16 x 1.2275 = 39.77 34 02213 0004 CY Native Soil/Dirt- Common 243.23 Quantity Unit Price Factor Total Installation 15.00 x 13.21 x 1-2275 243.23 35 02213 0004 CY Native Soil/Dirt - Common 243.23 Quantity Unit Price Factor Total Installation 15.00 x 13.21 x 1.2275 = 243.23 36 02213 0004 CY Native Soil/Dirt - Common 243.23 Quantity Unit Price Factor Total Installatian 15,00 x 13,21 x 1.2275 = 243,23 37 02213 0004 CY Native SoiVDirt - Common 162,15 Quantity Unit Price Factor Total Installation 10.00 x 13.21 x 1.2275 = 162.15 22 junie 2009 Page 3 of EZIQC Job Order Package 009202.00 $act item Mod. UDM Decriptlon Line Total 38 02213 0004 CY Native Soil/Dirt - Common 243.23 Quantity Unit Price Factor Total Installation 15.00 x 13.21 x 1.2275 = 243.23 39 02616 0025 EA Asphalt Placement For Smell Repair Areas, Hot Mix 875.07 Quantity Unit Price Factor Total Installation 1.00 x 712.89 x 1.2275 = 875,07 Subtotal for 02-SiteWork $11,355.10 Section 03-Concrete 40 03640 0003 CF Pressure Injected Cementitious Grout 21,021.98 Quantity Unit Price Factor Total Installation 1,465.00 x 11.69 x 1.2275 = 21.021.98 Subtotal for 03-Concrete $21,021.98 Section 15-Mechanical 41 15143 0011 64 10000 GPM Cast Iron Turbine Pump, 18" Discharge 100' Head, 2 Stage, 300 HP 1,903.61 Quantity Unit Price Factor Total Installation 0.00 x 68,268.58 x 1.2275 = 0.00 Demolition 2.00 x 775.40 x 1.2275 = 1,903.61 Subtotal for 15-Mechanical $1,903.61 Section 20- 42 20000 0006 Plug and Abandon Water Wall 10,065.50 Quantity Unit Price Factor Total NPP Task Installation 1.00 x 8,200.00 x 1.2275 10,005.60 Quota is based on a 1fr well and a 8", pull pump Subtotal for 20- $10,065.50 Project Proposal Total $53,516.46 The work order proposal total represents the correct total for the proposal. Any discrepancy between line totals, sub -totals and the proposal total is due to rounding of the line totals and sub -totals. 22 June 2009 Page 4 of 4 EZIQC Job Qrdet Pa dcap W 2MW 1 City of Lubbock Well Plugging Project The followin-a five have Brick structures... Footap-e on buildine will be about 12'xl2'x10'. • Well # 9... 2412 South East Dr. and Ivory Ave. Has pump in Well. Well building built Approximately around 1937. T.D...? • Well # IL. 3"d an Geneva Well building Built Approximately around 1938. T.D... 145' Static 37' Casing 12" • Well # 13.. 500 N. Ave U. An Emory Well building built approximately around 1939. T.D. 135' Static 37' Casing 16" • Well # 16.. Jarvis an Clovis Rd. Well building built approximately around 1941. T.D. 135' Static 4l' Casing 18" • Well # 78.. 5014 Ave G. Has pump in Well. In back yard. Well building built approximately around 1952. T.D. l59' Static N/A Casing N/A The Following Fifteen Wells have Steele Well Houses... • Well # 3.. Akon an 2"`' T.D. 136' Static 42' Casing 15" • Well # 4.. 2820 Amherst an Detroit T.D. 136' Static 40' Casing 18" • Well # 5-A.. fifth an Uvalde T.D. 149' Static 35' Casing N/A • Well # 10.. 1" an Vemon T.D. 138' Static 37' Casing 6" • Well # 12-A.. 3119 Emory Ave. an North Gary T.D. 136' Static 39' Casing 10' • Well # 22-A.. Municipal drive. West of public works Bldg. T.D. 132' Static 41' Casing 12" • Well # 25.. South of 2009 Baylor, Ave U. Near Clovis Rd.. T.D. 136' Static 38' Casing 16" • Well # 2% 913 E. Municipal Dr. T.D. 154' Static 27' Casing 12" • Well # 28-A.. 1703 E. Municipal Dr. Has small pump. T.D. 103' Static 74' Casing 16" • Well # 30.. 2101 E. loop 289 T.D. 136' Static 70' Casing 20" • Well # 32.. 1605 N. Guava Ave. T.D. 144' Static 85' Casing 12" • Well # 42.. 3700 E. Regis Ave. an E. Kent St. T.D. 158' Static NIA Casing 12" • Weil # 50.. 4600 Ursiline Ave. an Quaker Ave. T.D. 145' Static Casing • Well # 51.. Ursiline Ave. an Quaker Ave. T.D.144' Static Casing • Well # 52.. Ursiline Ave. an Quaker Ave. T.D.145' Static Casing Contractor will be responsible for all disposal of waste material. Contractor will be responsible for providing a safe zone so as to protect the public from any hazards during any construction of these projects. Contractor will be responsible for the top soil to be filled with the same material as the surrounding area of each well site. (Top soil, cement, asphalt etc....) Contractor will make sure the wells are plugged with a level beneath the surface of no less than Two feet below natural ground level. Under no circumstances will a well be left unattended during the plugging processes.... Plugging of Drilled Wells Chapter 76.1004 Original Ground Level Remove all removable casing. Pressure Cement well from bottom to surface. * Alternative Method Bentonite grout (10 lb. Per gallon or more with a marsh funnel viscosity of 54 sec. Or equiv.) Followed by a cemant plug from land surface to a depth of not less that 2 $. 1 T[emie Tube Total Depth of. I%.. r Yell Water Well Drillers and Pump Installers Administrative Rules Texas Administrative Code, Chapter 76 76.1004. Technical Requirements --Standards for Capping and Plugging of Wells and Plugging Wells that Penetrate Undesirable Water or Constituent Zones. (Effective January 3, 1999, 23 TexReg 13059; section repealed effective November 8, 2001, 26 TexReg8814; new section effective November 8, 2001, 26 TexReg 8814; amended effective December 1, 2003, 28 TexReg 10468; amended effective December 1, 2006, 31 TexReg 9604) (a) All wells which are required to be plugged or capped under Texas Occupations Code Chapters 1901 and 1902 or this Chapter shall be plugged and capped in accordance with the following specifications and in compliance with the local groundwater conservation district rules or incorporated city ordinances; (1) all removable casing shall be removed from the well; (2) any existing surface completion shall be removed; (3) the entire well pressure filled via a tremie pipe with cement from bottom up to the land surface; (4) In lieu of the procedure in paragraph (3) of this section, the well shall be pressure filled via a tremie tube with clean bentonite grout of a minimum 9.1 pounds per gallon weight followed by a cement plug extending from land surface to a depth of not less than two (2) feet, or if the well to be plugged has one hundred 100 feet or less of standing water the entire well may be tilled with a solid column of 3/8 inch or larger granular sodium bentonite hydrated at frequent intervals while strictly adhering to the manufacturers' recommended rate and method of application. If a bentonite grout is used, the entire well from not less than two (2) feet below land surface may be filled with the bentonite grout. The top two (2) feet above any bentonite grout or granular sodium bentonite shall be filled with cement as an atmospheric barrier. Bentonite grout may not be used if a water zone contains chlorides above 1500 ppm or if hydrocarbons are present. (5) Undesirable water or constituents shall be isolated from the fresh water zone(s) with cement plugs and the remainder of the wellbore tilled with neat cement or clean bentonite grout of a minimum 9.1 weight followed by a cement plug extending from land surface to a depth of not less than two (2) feet. (b) Large hand dug and bored wells 36-inches or greater in diameter to one hundred (100) feet in depth may be plugged by back filling with compacted clay or caliche to surface. All removable debris shall be removed from the well. If the well contains standing water, it shall be chlorinated by adding chlorine bleach at a rate of one (1) gallon of bleach for every five hundred (500) gallons of standing water. The backfill material shall be mounded above the surrounding surface to compensate for settling. (c) Wells which do not encounter groundwater (dry holes) may be plugged by backfilling with drill cuttings from total depth to the surface. The backfill material shall be mounded above the surrounding surface to compensate for settling. (d) Drillers may petition the Department, in writing, for a variance from the methods stated in subsection (a) of this section,. The variance should state in detail, an alternative method proposed and all conditions applicable to the well that would make the alternative method preferable to those methods stated in subsection (a) of this section. (e) A non -deteriorated well which contains casing in good condition and is beneficial to the landowner can be capped with a covering capable of preventing surface pollutants from entering the well and sustaining weight of at least four hundred (400) pounds and constructed in such a way that the covering cannot be easily removed by hand. Water Well Drillers and Pump Installers Law WATER WELL DRILLERS Texas Occupations Code Title 12. Practices and Trades Related to Water, Health, and Safety Chapter 1901 Administered by the Texas Department of Licensing and Regulation § 1901.255. Plugging Water Well (a) In this section: (1) "Abandoned well" means a well that is not in use. A well is considered to be in use if: (A) the well is not a deteriorated well and contains the casing, pump, and pump column in good condition; (B) the well is not a deteriorated well and has been capped; (C) the water from the well has been put to an authorized beneficial use, as defined by the Water Code; (D) the well is used in the normal course and scope and with the intensity and frequency of other similar users in the general community; or (E) the owner is participating in the Conservation Reserve Program authorized by Sections 1231-1236, Food Security Act of 1985 (16 U.S.C. Sections 3831-3836), or a similar governmental program. (2) "Deteriorated well" means a well that, because of its condition, will cause or is likely to cause pollution of any water in this state, including groundwater. (b) A driller who knows of an abandoned or deteriorated well shall notify the landowner or person who possesses the well that the well must be plugged or capped to avoid injury or pollution. (c) Not later than the 180th day after the date a landowner or other person who possesses an abandoned or deteriorated well learns of its condition, the landowner or other person shall have the well plugged or capped under standards and procedures adopted by the commission. (d) Not later than the 30th day after the date the well is plugged, a driller, licensed pump installer, or well owner who plugs an abandoned or deteriorated well shall submit a plugging report to: (1) the board of directors of the ground water conservation district in which the well is located, if the well is located in the boundaries of a groundwater conservation district; and (2) the executive director. (e) The department or the groundwater conservation district in which the well is located shall furnish plugging report forms on request. The executive director shall prescribe the content of the forms. Rpnnlntirrn Mn_ gnn —wri9F,1 exas apartment of License ana Regulation Water Well Driller/Pump lnstallerProgram This form must be completed P.O. Box 12157 Austin, Texas 78711 (512)463-7880 FAX (512)463-8616 and tiled with the department Email address: water.%vell alicense.state.tx.us within 30 days following the PLUGGING REPORT plugging ofthe well. A. WELL IDENTIFICATION AND LOCATION DATA i)OWNER Name Address CIN State lip 21WLLL LOCATION County Physical Address City State 7-ip- 3 Owner's Well No. Long. Lat. Grid N 4) Type of Well J Water J Monitor J Injection J De -Watering 5) NT Drill. Pump Installer, or Landowner performing the plugging operations must locate and identify the location of the well within a specific grid on a full scale Odded map available from Texas Natural Resource Information Serviee. The location of the well should be denoted within the grid by placing a corresponding dot in the square to the right. The legal description is optional. B) HISTORICAL DATA ON WELL TO HE PLUGGED (if available) 6) Driller License No. 7) Drilled / 1 TS) Diameter of hole Inches 1 9) Total depth of well feet. C. CURRENT PLUGGING DATA 10) Date well plugged / / I i) REMOVE ALL REMOVEABLE CASING Please check box beside the method of plugging used n V Tremmie pipe cement from bottom to top. O Tremmie pipe bentonite from bottom to 2 feet from From surface. cement top 2 feet. ` ;. Pour in 3/8 bentonite chips when standing water in well is less than 100 feet depth. cement top 2 feet. OLarge diameter well tilled with clay material from top to bottom. 112) Name of Driller/Pump Installer or Well Owner performing the plugging License No. 13) CASING AND CEMENTING DATA RELATIVE TO THE PLUGGING OPERATIONS CASING LEFT 1N WELL DIAMETER inches FROM feet TO feet CEM'E.NT/$ENTONITEPLUG(S) PLACES IN WELL FROM (feet) TO (feet) SACKS D. VALIDATION OF INFORMATION INCLUDED IN FORM I certify that I plugged this well (or the well was plugged under my supervision) and that all of the statements herein are true and correct. understand that failure to complete items I through 13 w ill result in the report(s) being returned for completion and resubmitted. Company or individual's Name (type or print) Address I City State Zip Licensed 04deriPamp Installer Date Appeutlte Date TDLRFyRMa(X)IWWD ifrhile -TDLR Yellow - Owner Pink - Driller/Pumpinstaller Resolution No. 2009—RO261 City of Lubbock Job Order This Job Order is governed by all terms and conditions of the Contract referenced below which is hereby incorporated by reference. Owner: Wesley Everett, Director of Facilities Management for Water Production Well Plugging NJPA Contract No.: Tx04-061908-TAL, National Joint Powers Alliance (NJPA), Indefinite Quantity Construction Contract. Contract Job Order no.: 09-051-F-051-NJPA Contractor: TalonJLPE. Date of Contract: September 25, 2008 Job Order Date: June 24, 2009 Project Architect for this Job Order: List name, phone number and firm name of Architect contracted for this project. N/A Summary and Description of Statement of Work attached hereto: Plug and Abandon Fifteen Obsolete Water Wells. Talon Job Order Number: 009202.00 hereto attached. Value of pre -priced work: 166,853.99 Value of non -pre -priced work: 00.00 Payment and Performance Bonds: $3,518.63 Insurance Requirements per Exhibit A, attached. Total Fixed Price stipulated sum for this Job Order ("Job Order Sum"): $ 70,372.62 Notice to Proceed Date for this Job Order: To be issued after City Council approval Expected Completion Date for this Job Order: To be determined after City Council approval Liquidated Damages (if different than as set forth in Agreement): $25 per day CONTRACTOR: CITY OF LUBBOCK, TEXAS (OWNER): Talon/LPE. By: PRINTED NAME: BRIDGER HOWARD TITLE: PROJECT MANAGER COMPLETE ADDRESS: Company TalonlUE Address 921 N. Bivins Street City, State, Zip Amarillo, TX 79107 ATTEST: Corporate Secretary By: .s,►.�--- l�� MAYOR - ATTEST: City ecretary APPROVED AS TO CONTENT: 0-\ Purc6aseTublic Works ContractingVA Order Contracts 6,24)2009 "EXHIBIT A" Resolution No. 2009-RO261 ACORD. CERTIFICATE OF LIABILITY INSURANCE I 12`241013 O.YYYY PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hilb Fiogal & Hobbs of Amarillo ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1800 Washington, Suite 400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. POSox1149 Amarillo, TX 79105-1149 INSURERS AFFORDING COVERAGE NAIC it i > i NSOREo IhSLRER A American Intl Specialty I 67763 Talon/LPE, Ltd. NSLaLRB: Texas Mutual insurance Company 22945�� 921 N. Sivins Street l .tisLHeR America First Insurance 12696 Amarillo, TX 79107 IN;,, NERC � Ih'5:;REH E: j COVERAGES T,r POL'�CIES OF INSURANCE LISTED SELCW HAVE SEEN ISSUEO TO THE INSURED NAh,4E0 ABOVE FOR THE POLICY F'�R1C0 IFiDICATtO. NOTbVITHSTA"v�ING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRAGT OR OTHER QOCUMENT 'KITH RESPECT TO WHSCH THIS CERTIFICATE MAY BE iSSLEO OR NIA'r PERTAIN, THE INSURANCE AFFORDED BY I Fit POLICIES CESCRISEO HEREIN iS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONCITI�JNS CF $UCH PP!L!C: ES. AGGREGATE LIMITS SHOWN MAY HAVE SEEN RZDUCEC By VA!0 CukMS- TYPE OF INSURANCE POLICY NUMBER POLICY EFFEC IVE POLICY EXPIRATION M: LIMITS rA GENERALLw81UTY PROP14225734 12/31108 EACHGCCURRENCE si 000000 ' X cwMMERCIAL GENERAL LtANLITY I12/31/09 CA1.4>r(3F TC RE+^ITED r s300 000 CLAIMS MADE � OCCUR I� I ! ME0 EXP {Any Cie ¢.orcr.? sMOOO I PERS,.,WL a ADV !N4L RY S1,000,000 X I PD Ded:10.000 GENERAL AGGREGATE S2 00O 000 FGEIN,'L AGGREGATE LIMIT APPLIES PER: FROCUCTS • CCMP!CP AGG s2,000,000 POLICY PROT LOG C AUTOMOBILE X LL481LITY ANY AUTO BA8369955 12/31/08 12/31/09 COUBINED Eaa=deMy INGLELIMI7 $1,000,000 BODILY INJURY IPer person) $ ALL OWNED AUTOS SCHEDULED AUTCS I 6001LY INJURY (Per xdderl) S X X HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per ecudenq s I+ GARAGE LIABILITY AUTO ONLY - EAACCIOENT S CTHER THAN EA ACC S ANY AUTO I S AUTO ONLY. AGO A EXCESSIUMaRELLA LIABILITY X OCCUR ❑ CLAIMS MADE PROU14225993 12131/08 12/31/09 EACH OCCURRENCE S9,000,000 AGGREGATE $9 00O 000 f S DEDUCTIBLE $ X RETENTION $10000 B WORKERS COMPENSATION AND TSF0001155583 12/31/08 12131109 wORX e 1,. 0. B EMPLOYERS UABJUTY ANY PROPRIETORrPARTNMEXECUTIVE E.L. EACH ACCIDENT S1,000,000 E.L.. DISEASE - EA EMPLOYEE 51,000,000 OFFICERIMEMBER EXCLUDED? Ifyee, daeenW antler SPECIAL PR VISIONS below E.L. 015EASE- POLICY LIMIT ` S1,000000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT t SPECIAL PROVISIONS It is hereby understood and agreed that the certificate holder is an additional insured on the general liability and the general liability is primary- A waiver of subrogation applies on the general liability, automobile and workers compensation coverage. The general liability does (See Attached Descriptions) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPISA70h City Of Lubbock :DATE THEREOF, THE ISSUINGINSURER WILL ENDEAVOR TOMAX _—jQ_ DAYS WRITTEN 1625 13th Street NOTICE TO T14E CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALT. Lubbock, TX 79414 IMPOSE NO OBLIGATION OR LIABILITY OF ANY XIND UPON THE INSURER, ITS AGENTS OR TREPRESENTATIVES. AUTHORII.EO REPRESENTATIVE At;VRLJ 25 t20041OBi 1 of 3 #M71243 LGM o ACORD CORPORATION 4988 "EXHIB.IT A" IMPORTANT If the certificate holder is an ADDITIONAL_ INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon_ ravunu L5-5 tzuuzruol 2 03 #M71243 "EXHIBIT A" AMS 25.3 (2001108) 3 of 3 #M71243 Contractor's Cost Proposal Detail - CSI Date. 06/22/2009 Basic Project Information Job Order Number: 009202,00 Job Order Name: Pump house Demo Contractor: Talon/LPE Proposal Name: Pump house Plug only Proposal Value: $70,372.62 Brief Scope: Pump House Demolition Sect Item Mod. UOM Decrlption Line Total Section 01-General Requirements 1 01352 0044 HR Investigating Engineer Or Specialty Consultant,Note: For special investigating 491.00 requirements or services outside required architectural and engineering services Quantity Unit Price Factor Total installation 5.00 x 80.00 x 1.2275 = 491.00 NESHAP Certified Individual On Site During Demolitions 2 01590 02W WK 36" Wde, 1J8 CY Bobcat, With Full -Time Operator 3,146.99 Quantity Unit Price Factor Total Installation 2.00 x 1,281.87 x 1.2275 = 3,146.99 3 01590 0754 WK 1-1/2 Ton Flat Bed Truck, 4 x 2, With Full -Time Truck DriverNote: Includes hydraulic 4,514.92 tiltbed. Quantity Unit Price Factor Total Installation 2.00 x 1,839.07 x 1.2275 = 4,514.92 4 01590 0764 WK 3/4 Ton Light Duty Truck, 4 x 4 Crew PickupNote: With full-time truck driver 4,344.32 Quantity Unk Price Factor Total Installation 2.00 x 1,769.58 x 1.2275 = 4,344,32 5 01590 0817 EA Bobcat DeliveryfMob/DemobNote: Use for bobcat or similar sized equipment. Includes 123.83 delivery fee, delivery, set-up and return. Quantity Unit Price Factor Total Installation 1.00 x 100.88 x 1.2275 = 123.83 Subtotal for 01 -General Requirements $12,621.06 Section 02-SlteWork 6 02115 0040 HR Hourly Office Work For Both For Reports Required For EPA. Includes Title Searches, 1,674.06 Well Survey Data, Drawing Site Drawings. Filing preliminary work with EPA for feedback, Prepare on CAP -A and CAP-8 plans, etc. Hours not to be used in association with other tasks performed. Quantity Unit Price Factor Total Installation 30.00 x 45.46 x 1,2275 = 1,674,06 7 02616 0025 EA Asphalt Placement For Small Repair Areas, Hot Mix 875.07 Quantity Unit Price Factor Total Installation 1.00 x 712.89 x 1.2275 = 875.07 Subtotal for 02-SiteWork $2,549.13 22 Jun.s 2009 Page 1 of 2 L EZlQC Job Older Package 009202.00 I sect Item Mod. UDM Decrlption Line Total Section 03-Concrete 8 03640 0003 CF Pressure Injected Cementitious Grout Quantity Unit Price Factor Total Installation 3,847.00 x 11.69 x 1.2275 = 55.202.43 143 Cubic Yards of concrete fill Subtotal for 03-Concrete 55,202.43 $55,202.43 Project Proposal Total $70,372.62 The work order proposal total represents the correct total for the proposal- Any discrepancy between line totals, sub -totals and the proposal total is due to rounding of the line totals and sub -totals. 22 June 2009 Page 2 of 2 EZIQC,Job Order Pad<age 009202.00 �p City of Lubbock Well Pluagin2 Project The following five have Brick structures... Footay-e on building will be about 12'xl2'x10'. • Well # 9... 2412 South East Dr. and Ivory Ave. Has pump in Well. Well building built Approximately around 1937. T.D...? • Well # 11.. 3"d an Geneva Well building Built Approximately around 1938. T.D... 145' Static 37' Casing 12" • Well # 13.. 500 N. Ave U. An Emory Well building built approximately around 1939. T.D. 135' Static 37' Casing 16" • Well # 16.. Jarvis an Clovis Rd. Well building built approximately around 1941. T.D. 135' Static 4F Casing 18" • Well # 78.. 5014 Ave G. Has pump in Well. In backyard. Well building built approximately around 1952. T.D. 159' Static N/A Casing N/A The Following Fifteen Wells have Steele Well Houses... • Well # 3.. Akan an 2'd T.D. 136' Static 42' Casing 15" • Well # 4.. 2820 Amherst an Detroit T.D. 136' Static 40' Casing 18" • Well # 5-A.. fifth an Uvalde T.D. 149' Static 35' Casing N/A • Well # 10.. I st an Vernon T.D. 138' Static 37' Casing 6" • Well # 12-A.. 3119 Emory Ave. an North Gary T.D. 136' Static 39' Casing 10' • Well # 22-A.. Municipal drive. West of public works Bldg. T.D. 132' Static 4 1 ' Casing 12" • Well # 25.. South of 2009 Baylor, Ave U. Near Clovis Rd.. T.D. 136' Static 38' Casing 16" • Well # 2% 913 E. Municipal Dr. T.D. 154' Static 27' Casing 12" • Well # 28-A.. 1703 E. Municipal Dr. Has small pump. T.D. 103' Static 74' Casing 16" • Well # 30.. 2101 E. loop 289 T.D. 136' Static 70' Casing 20" • Well # 32.. 1605 N. Guava Ave. T.D. 144' Static 85' Casing 12" • Well # 42.. 3700 E. Regis Ave. an E. Kent St. T.D. 158' Static N/A Casing 12" • Well # 50.. 4600 Ursiline Ave. an Quaker Ave. T.D.145' Static Casing • Well # 51.. Ursiline Ave. an Quaker Ave. T.D.144' Static Casing • Well # 52.. Ursiline Ave. an Quaker Ave. T.D.145' Static Casing Contractor will be responsible for all disposal of waste material. Contractor will be responsible for providing a safe zone so as to protect the public from any hazards during any construction of these projects. Contractor will be responsible for the top soil to be filled with the same material as the surrounding area of each well site. (Top soil, cement, asphalt etc....) Contractor will make sure the wells are plugged with a level beneath the surface of no less than Two feet below natural ground level. Under no circumstances will a well be left unattended during the plugging processes.... Original Ground Level Remove all removable casmg. t t L F!�ressure Cement well from bottom to surface. * Altemative Method Tremie Tube Bentonite, grout (10 lb. Per gallon or more with a marsh ftmel viscosity of 50 sec. Or equiv.) Total Depth of Well Followed by a cemant plug ftom land surface to a depth of not less that 2 ft. A& I I A Water Well Drillers and Pump Installers Administrative Rules Texas Administrative Code, Chapter 76 76.1004. Technical Requirements --Standards for Capping and Plugging of Wells and Plugging Wells that Penetrate Undesirable Water or Constituent Zones. (Effective January 3, 1999, 23 TexReg 13059; section repealed effective November 8, 2001, 26 TexReg8814; new section effective November 8, 2001, 26 TexReg 8814; amended effective December 1, 2003, 28 TexReg 10468; amended effective December 1, 2006, 31 TexReg 9604) (a) All wells which are required to be plugged or capped under Texas Occupations Code Chapters 1901 and 1902 or this Chapter shall be plugged and capped in accordance with the following specifications and in compliance with the local groundwater conservation district rules or incorporated city ordinances: (1) all removable casing shall be removed from the well; (2) any existing surface completion shall be removed; (3) the entire well pressure filled via a tremie pipe with cement from bottom up to the land surface; (4) In lieu of the procedure in paragraph (3) of this section, the well shall be pressure filled via a tremie tube with clean bentonite grout of a minimum 9.1 pounds per gallon weight followed by a cement plug extending from land surface to a depth of not less than two (2) feet, or if the well to be plugged has one hundred 100 feet or less of standing water the entire well may be filled with a solid column of 318 inch or larger granular sodium bentonite hydrated at frequent intervals while strictly adhering to the manufacturers' recommended rate and method of application. If a bentonite grout is used, the entire well from not less than two (2) feet below land surface may be filled with the bentonite grout. The top two (2) feet above any bentonite grout or granular sodium bentonite shall be filled with cement as an atmospheric barrier. Bentonite grout may not be used if a water zone contains chlorides above 1500 ppm or if hydrocarbons are present. (5) Undesirable water or constituents shall be isolated from the fresh water zone(s) with cement plugs and the remainder of the wellbore filled with neat cement or clean bentonite grout of a minimum 9.1 weight followed by a cement plug extending from land surface to a depth of not less than two (2) feet. (b) Large hand dug and bored wells 36-inches or greater in diameter to one hundred (100) feet in depth may be plugged by back filling with compacted clay or caliche to surface. All removable debris shall be removed from the well. If the well contains standing water, it shall be chlorinated by adding chlorine bleach at a rate of one (1) gallon of bleach for every five hundred (500) gallons of standing water. The backfill material shall be mounded above the surrounding surface to compensate for settling. (c) Wells which do not encounter groundwater (dry holes) may be plugged by backfilling with drill cuttings from total depth to the surface. The backfill material shall be mounded above the surrounding surface to compensate for settling. (d) Drillers may petition the Department, in writing, for a variance from the methods stated in subsection (a) of this section. The variance should state in detail, an alternative method proposed and all conditions applicable to the well that would make the alternative method preferable to those methods stated in subsection (a) of this section. (e) A non -deteriorated well which contains casing in good condition and is beneficial to the landowner can be capped with a covering capable of preventing surface pollutants from entering the well and sustaining weight of at least four hundred (400) pounds and constructed in such a way that the covering cannot be easily removed by hand. Water Well Drillers and Pump Installers Law WATER WELL DRILLERS Texas Occupations Code Title 12. Practices and Trades Related to Water, Health, and Safety Chapter 1901 Administered by the Texas Department of Licensing and Regulation § 1901.255. Plugging Water Well (a) In this section: (1) "Abandoned well" means a well that is not in use. A well is considered to be in use if: (A) the well is not a deteriorated well and contains the casing, pump, and pump column in good condition; (B) the well is not a deteriorated well and has been capped; (C) the water from the well has been put to an authorized beneficial use, as defined by the Water Code; (D) the well is used in the normal course and scope and with the intensity and frequency of other similar users in the general community; or (E) the owner is participating in the Conservation Reserve Program authorized by Sections 1231-1236, Food Security Act of 1985 (16 U.S.C. Sections 3831-3836), or a similar governmental program. (2) "Deteriorated well" means a well that, because of its condition, will cause or is likely to cause pollution of any water in this state, including groundwater. (b) A driller who knows of an abandoned or deteriorated well shall notify the landowner or person who possesses the well that the well must be plugged or capped to avoid injury or pollution. (c) Not later than the 180th day after the date a landowner or other person who possesses an abandoned or deteriorated well learns of its condition, the landowner or other person shall have the well plugged or capped under standards and procedures adopted by the commission. (d) Not later than the 30th day after the date the well is plugged, a driller, licensed pump installer, or well owner who plugs an abandoned or deteriorated well shall submit a plugging report to: (1) the board of directors of the ground water conservation district in which the well is located, if the well is located in the boundaries of a groundwater conservation district; and (2) the executive director. (e) The department or the groundwater conservation district in which the well is located shall furnish plugging report forms on request. The executive director shall prescribe the content of the forms. Resolution No. 2009-R2061 Tex —as Department of L>Icense and Regulation Water Well Driller/Pump lnsiaderPmgram This form must be completed P.O. Box 12157 Austin, Texas 78711 (512)463-7880 FAX (512)463-8616 and fled with the department Email address: water. welIPa_license.state. tx.us within 30 days following the PLUGGING REPORT plugging ofthe well. A. WELL IDENTIFICATION AND LOCATION DATA I) OWNER Name Address City State Zip WELL LOCATION County Physical Address City State Zip 3 Owner's Well No. Lona. ILat. Grid # 4) Type of Well Water Monitor Injection De -Watering 5) NT Drill, Pump Installer, or Landowner performing the plugging operations must locate and identify the location of the well within a specific grid on a full scale gridded map available from Texas Natural Resource Information Service. The location of the well should be denoted within the grid by placing a corresponding dot in the square to the right The legal description is optional. B) HISTORICAL DATA ON WELL TO DE PLUGGED (if available) 6) Driller License No, 7) Drilled 1 / 8) Diameter of hole Inches 1 9) Total depth of well feet. C. CURRENT PLUGGI NG DATA 10) Date well plugged / / 1 I) REMOVE ALL REMOVEABLE CASING Please check box beside the method of plugging used LJTremmie pipe cement from bottom to top. O Tremmie pipe bentonite from bottom to 2 feet from From surface, cement top 2 feet. L) Pour in 318 bentonite chips when standing water in well is less than 100 feet depth, cement top 2 feet. Large diameter well filled with clay material from top to bottom. 12) Name of Driller/Pump Installer or Well Owner performing the plugging License No. 13)CASING ANDCEMENTINGDATARELATIVETOTHEPLUGGINGOPERATIONS CASING LEFT IN WELL DIAMETER finchesl FROM feet TO fe CEMENTIRKNTONITE FROM (feet) PLUG(S) PLACES IN WELL TO (f�) SACKS D. VAWDATION OF INFORMATION INCLUDED IN FORM I certify that I plugged this well (or the well was plugged under my supervision) and that all of the statements herein are true and correct. I understand that failure to complete items I through 13 will result in the report(s) being returned for completion and resubmitted. Company or individual's Name (type or print) Address City State Zip Uremcd MIUvrRamp bgn*br Vtlte Appsudce Vale TDLRFORM a0o4WWD W7t/te-TDLR Yellaw-Owner Pink -Drdler/Pumpinstaller