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Resolution - 2009-R0261 - Contract - Talon/LPE - Demolition And Plugging Of Water Wells And Well Houses - 07/08/2009
Resolution No. 2009-80261. July 8, 2009 Itear 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 ATTEST: TOM MARTIN, MAYOR i Rebe a Garza, City Secretary AS TO CONTENT: Lltd('L�74'7 �11;��-1-2c:�--- Aubrey Spear, P,#.-, Direct9f of Water Utilities APPROVED AS TO FORM: , City Attorney Dares/ I'alonLPE-NJPACon09 WaterRes June 24, 2009 2009 Resolution No. 2009-84261 City of Lubbock Job Order This .lob 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-TAI., 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. NZA 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: 00.04 Payment and Performance Bonds: $2,675.82 Insurance Requirements per Exhibit A, attached. Total Fixed Price stipulated sum for this Job Order (".lob Order Scam"): $ 53.516.46 Notice to Proceed Date for this Job Order: To be issued after City Council approval oval Expected Completion Date for this Job Order: To be determined after City Council approval Liquidated Damages (if different than as set forth in Agreement): $L5 per day CONTRACTOR: CITY OF LUBBOCK, TEXAS (OWNER): Talon/LPE. By: "C;z PRINTED NAME: BRIDGER HOWARD TITLE: PROJECT MANAGER COMPLETE ADDRESS: Company Talon(LPE Address 921 N. Bivins Street City, State, Zip Amarillo, TX 79107 ATTEST: Corporate Secretary By: MAYOR ATTEST: City *cretary APPROVED AS TO CONTENT: OyMer's Representa0e Director Q:1 PurchaselPublic works Contract ing\i ob order Contracts 6124/2009 "EXHIBIT A" Resolution No. 2009-R0261 DATE IYUAIU4J:YYYY1 A CO \U. 12)2 �..� CERTIFICATE OF LIABILITY INSURANCE 12r2arpa PRoou�ER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Nitb Ragal 8 Hobbs of Amarillo ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 18()o Washington, Suite 400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, POgox1149 Amarillo, TX 79105-1149 INSURED Talon/LPE, Ltd. 921 N. Bivins Streel Amarillo, TX 79107 INSURERS AFFORDING COVERAGE i NAIC # ,NSLRER A. American Intl Specialty 67763 ,NsURERE: Texas Mutual Insurance Company 22945 ;NSUR$Rc. America First Insurance j 12696 EFFECTIVE POLICY EXPIRATIONr 1 NS�fiER E: V V V Cl*.nvc.� THE P-OUCILS OF iNSURANCE LISTED BELOW HAVE BEEN iSSUEO TC THE INSURED NAMED ADOVE FOR THE POLICY PERIOD +NDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCU MEN r 'KITH RESPECT', 0 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY I'HE PCLICtES CESCRIBLO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SI.JCH PCLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN RECUCEC BY PAO CLAIMS. INWm5ulLPOLICY EFFECTIVE POLICY EXPIRATIONr LIMITS TYPE OF INSURANCE POLICY NUMBER LTR A GENERAL LLAB41JTY PROP14225734 12131/08 12131109 °. EACH H Ok n 51 000 000 CURS a cs r. —:— $300,000 II aI }(__.'COMMERCIAL GENERAL LkADILIT'f FRED EXP .Any cne perurj s25,000 CLAIMS MACE 15:1 OCCUR PERSONAL & ADV IN A RY $1 000 000 X ! PD Ded:10 OOO GEN' EAAL AGGREGATE $Z OQO O0O GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS CCMP!OP AGG S2 000 000 PRO' LOC POLICYEl JEct C AUTOMOBILELIABILIT'Y BA8369955 12131/08 12131109 COMBINED SINGLE LIMIT 51,000,004 lEe acddernS _-- X ANY AUTO ALL OWNED AUTOS I BODILY INJURY S +,Per paxanS -- SCHEDULED AUTOS BODILY INJURY S X HIREDAUTOS i (Pere ddenk) X, NON-OWNEO AUTOS Ij ! PROPERTY DAMAGE 5 rPer eccdentJ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC S ANY AUTO AUTO ONLY, AGG S A EXCES9MMBRELLA LIABILITY PROU14225993 12131./08 12/31109 EACHOCCURRENCE $9,000,000 AGGREGATE $9,000,000 _ X OCCUR FICLAIMS MADE III $ DEDUCTIBLE - $ X RETENTION $ 10000 B WORKERS coMPENBAn ON AND TSFOOOI 155583 12131108 12/31/09 OR I IMIT om- El EACH ACCIDENT 51,000,000 B FMPLOYERT LULBIUTY E.L. DISEASE- EA EMPLOYEE S110001000 ANY PRCPRIETORrPARTNER;EXE:CUTtVE OFFICERIMEMBER EXCLUDED? E.L- DISEASE -POLICY L:M{T $1,000,000 M yyes, devwt;q aP ECIAL PROVISIONS below wider OTItER DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES 1 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) I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Lubbock I OATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN 1825 13th Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Lubbock, TX 79414 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVE ACORD 25 (2801108) 1 of 3 #M71243 LGM 0 AL;UKU L;UKF'UKA I IUN lyao "EXHIBIT Ab' 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 chis 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. ACORD 25-5 (2001108) 2 of 3 #M71243 "EXHIBIT A" AMS 25.3 (2001108) 3 of 3 #M71243 fIQC Contractor's Cost Proposal Detail - CSI Date : 46/2212009 Basic Protect 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. Item Mod. UOM Decriptlon 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 engineertng 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" Wide, 118 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 Bed Truck, 4 x 2, With Full -Time Truck DriverNote: Includes hydraulic 2,257.46 tkltbed. Quantity Unit Price Factor Total Installation 1.00 x 1,839.07 x 12275 = 2,257.46 4 01590 0764 WK 314 Ton Light Duty Truck, 4 x 4 Crew PickupNote: With full-time truck driver 2,172.16 Quantity Unit Price Factor Total Installation 1,00 x 1,769.58 x 1.2275 = 2,172.16 5 01590 0817 EA Bobcat Delivery/Mob/DemobNote: Use for bobcat or similar sized equipment. Includes 619.15 delivery fee, delivery, set-up and return. _ Quantity Unit Price 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 Delivery/Mob/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 Delivery/Mob/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 6 01$90 0818 EA Backhoe, Dozer Or Roller Up To 250 HP DeliveryfMob/DemobNoie: Use for backhoe, 411.40 dozer, roller, loader, excavator or similar sized equipment. Includes delivery fee, delivery, set-up and retum. Quantity Unit Price Factor Total Installation 1.00 x 335.15 x 1.2275 = 411,40 22 June 2009 Page 1 of 4 EZ10C Job Order Package 009202.00 1 Sect. Item Mod. UOM Decriptlon Line Total 9 01590 0818 EA Backhoe, Dozer Or Roder Up To 250 HP DeliverylMoblDemobNote: 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 10 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, set-up and return. Quantity Unit Price Factor Total Installation 1.00 x 335,15 x 1.2275 = 411.40 Subtotal for 01 -General Requirements $9,170.27 Section 02 -Site Work 11 02111 0015 CCF Demo Masonry Building With Bulldozer/Excavator Remove Building 431,47 Quantity Unit Price Factor Total Installation 25.00 x 14.06 x 1.2275 = 431.47 12 02MOD 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 1.2275 = 258.88 14 02111 0015 CCF Demo Masonry Building With Bulldozer/Excavator 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 Bulldozer/Excavator Remove Building 258.88 Quantity Unit Price Factor Total Installation 15,00 x 14.06 x 1.2275 = 258.88 16 02111 0015 CCF Demo Masonry Building With Bulldozer/Excavator Remove Building 258.88 Quantity Unit Price Factor Total Installation 15.00 x 14,06 x 1.2275 = 258.88 17 02112 0088 CF 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 CF 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 19 02112 0088 CF 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 CF 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 CF 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 CAR -A and CAP -B plans, etc. Hours not to be used in association with other tasks performed. Quantity Unit Pace Factor Total Installation 10.00 x 45,46 x 1.2275 = 558.02 22 June 2008 Page 2 of 4 EZIQC Job Order Package 009202.00 10 Sect. Item Mod. UOM Decrlplion Line Total 23 02119 0014 CYM Hauling On Paved Roads, First 15 Miles 02119 15467 Quantity Unit Price Factor Total Installation 280.00 x 0.45 x 1.2275 = 15467 24 02119 0014 GYM Hauling On Paved Roads, First 15 Miles Total 154.57 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 02119 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 Price Factor Total Installation 280.00 x 0.45 x 12275 = 154.67 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 Total 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 Unit Price 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 Backhoe. Loader Quantity Unit Price Factor Total Installation 10.00 x 2.16 x 1.2275 = 26.51 33 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 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 Installation 15.00 x 13.21 x 1.2275 = 243.23 37 02213 0004 CY Native Soil/Dirt - Common 162.15 Quantity Unit Price Factor Total Installation 10.00 x 13.21 x 1.2275 = 162.15 22 June 2009 Page 3 of 4 EZIQC Jab Order Package 009202.00 10 Sect. Item Mod. UOM Decription 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 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 $11,355.10 Section 03 -Concrete 40 03640 0003 CF Pressure Injected Cementitious Grout 21,021.98 Quantity Unit Pnce Factor Total Installation 1,465.00 x 11.69 x 1.2275 = 21,021.96 Subtotal for 03 -Concrete $21,021.98 Section 15 -Mechanical 41 15143 0011 EA 10000 GPM Gast 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 0005 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 = 10,065.50 Quote is based on a 16" well and a 8", pull pump Subtotal for 20- $10,065.60 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 F_ZIQC Job Order Package 00$202.00 10 City of Lubbock Well Plugging Pro n+ The followin-a five have Brick structures... Footage on buildinp- 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 193 8. 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 # lb.. Jarvis an Clovis Rd. Well building built approximately around 1941. T.D. 135' Static 41' Casing 18" • Well # 78.. 5014 Ave G. Has pump in Well. In back yard. Well building built approximately around 1952. T.D. 159' Static NIA Casing NIA The Fotlowina 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 NIA • Well # 10.. 1" 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 41' Casing 12" • Well # 25.. South of 2009 Baylor, Ave U. Near Clovis Rd.. T.D. 136' Static 38' Casing 16" • Well # 27.. 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" • 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 casing. Pressure Cement well from bottom to surface. * .�ter�nqtiyqe hdethod Bentonite grout (10 1. Per gallon or more with a marsh funnel viscosiq,- of 50 sec. Or equiv.) Followed by a cemant plug fi-om land surface to a depth of not less that 2 ft. is Tube Total Depth of Well 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 S, 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 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. uo-„i„l`in„ Al- 9nn4_Rn9fit Texas Department of Licen-se-a-M(Megura-Mon Water Well Driller/Pump Installer Program This ti nn must be completed P.O. Box 12157 Austin, Texas 78711 (512)463-7880 FAX (512)463-8616 and tiled with the department within 341 days following the Email address: ++ater.++ell u�licrnse.state. tx.us plugging oFthewell PLUGGING REEORT A. WELL IDENTIFICATION AND LOCATION DATA 1)OWN ER Name Address City State Lip 21WELL LOCATLON County Physical Address City State Zip 3 Owner's Well No. Lone. Lat. Grid it 4) Type of Well LJ Water LJ Monitor Injection LJ De -Watering 5) T Drill, Pump Installer, or Landowner performing the plugging operations must locate and identikr the location of the well within a specific grid on a Full scale gridded map a+ailable From Texas Natural Resource Information Service. The lm:ation ofthe+%ell should be denoted within thegrid by placing a corresponding dot in the square to the right. The legal description is optional. B) HISTORICAL DATA ON W ELL TO BE PLUGGED (if available) 6) Driller License No. 7)DriIled / f 8) Diamrterofhole Inches I 9)Total depth orweil feet. C. CURRENT PLUGGING DATA 10) Date well plugged i / i l) REMOVE ALL REMOVEABLE CASING Please check box beside the method of plugging used 'fremrnir pipe cement from bottom to top. O Tremmic pipe bentonite from bottom to 2 feet from From surface, cement top 2 feet. O Pour in 318 bentonite chips when standing water in well is less than 100 feet depth, cement top 2 feet. LjLarge diameter well tilled with clay material from tap to bottom. 12) 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 IN WELL DIAMETER-Linches FROM(feet) TO Peet CFIM 'E.NTIIIENTONITEPLUG(S) PLACES IN WELL C©MNIENTS FROM (feet) TO (feet) SACKS D. VALIDATION OF INFORMATION INCLUDED IN FORM I certify that I plugged this ++ell (or the %% ell +gas plugged under m+ 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 Cit}' State lip Licemed DcillevVemp Installer nate Apineatiee Date TDl-RFQRMatXYtWW'D White -TDLR Yellow - Owner Pink - Driller/PumpInsraller 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.: 09-451-F-051-NJPA Contractor: Talon/LPE. Date of Contract: September 25, 2008 Job Order Date. June 249 2409 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: 409202.00 hereto attached. Value of pre -priced work: 66 853.99 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 sura 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): $25 per clay CONTRACTOR: CITY OF LUBBOCK TEXAS (OWNER): Talon/LPE. By: PRINTED NAME: BRIDGER HOWARD TITLE: PROJECT MANAGER COMPLETE ADDRESS: Cornpany Talon/LPE Address 921 N. Bivins Street City, State, Zip Amarillo, TX 79107 ATTEST: Corporate Secretary 3 By: MAYOR ATTEST: City ecretary APPROVED AS TO CONTENT: X14 � 4:1 PurdrasOubiic Works Cowracling\Job order COMMCE$ 6/24/2409 "EXHIBIT A" Resolution No. 2009-RO261 ACORD„w CERTIFICATE OF LIABILITY INSURANCE 2124/1MiOD:YYYY 12l24IOB PRODUCER THIS CERTIFICATE is issuED AS A MATTER OF INFORMATION PROD CER 8 Hobbs of Amarillo 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. POgox1149 Amarillo, TX 79105-1149 INSURERS AFFORDING COVERAGE NAtC # ksuREo ,M1=LR€RA American Intl Specialty 87753 TalonfLPE, Ltd. : ,SLRLRB: Texas Mutual Insurance Company 22945 921 N. Bivins Street Amarillo, TX 79107 NsLR�Rc. America First insurance 12696 ;Ns RER C. INSURER E: GVYtf�I"tvca THE POUCiES OF INSURANCE LISTED BEL'J'A! HAVE BEEN ISSUED TO THE. INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT'NITHSTA`+DIN'_ ANY RE©UPREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT'NiTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ,10A'r PERTAIN, THE INSURANCE AFFORCED BY 1'HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI- THE TERMS, EXCLUSIONS ANC CONDITIONS CF $UCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN RECUCEC BY PAID CLAIMS{fu City of Lubbock ; DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3d DAYS WRITTEN 1625 13th Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHAtL POLICY €FFECTNE POLICY EXE !RATION LIMITS TYPE OF INSURANCE POLICY NUMBER LTA A a�ERAa LlaeluTY - PROP14225734 12!31!08 12131/03 EACHcccsRRENCE S1,000 �O00 L'A1.IAr(£ TO..RENTED rQ 530 OOO �( C'wMM€RLIAL GENERAL LIAB;LITY i oneemc MED EXP {Any Fr.) 525 000 - II CLAIMS MALE � CGGI:rZ ! �IN_URY S1,000,000 aE—NS,N—ALa— ADV i X I PD Ded:10,000 GENERA! LAGGREGATE S2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS � COMPICP AGG S2 000 000 POLICY PrLOC C AUTOMaBILE LIABILITY BA8369955 12131108 12131109 COMBINED SINGLE C&IT $1,000,000 X iEa acddenly ANY AUTO ALL OWNED AUTOS I BODILY INJURY $ (Per jwwm) _- SCHEDULED AUTOS BODILYINJURY S X HIRED AUTOS I !Par xradenl) X NON-OWNEDAUTCS PROPERTY DAMAGE S !Per acvdent) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACG S ANY AUTO AUTO ONLY: AGO S A UCESSIUMBRELLA LIABILITY PROU14225993 12J31108 12131109 EACH OCCURRENCE S9.000.000 AGGREGATE $9,000,000 X OCCUR ❑ CLMMS MADE S S DEDUCTIBLE X RETENTION $10000--j 10000S B WORKERS COMPENSATION AND TS F0001155583 12131/08 12/31109 wG sTATu- OT?I- E.L. EACH ACCICENI' S1,000,000 B EMPLOYERS' LIA91LITY E.L.. DISEASE - EA EMPLOYEE $1,000.,000 ANY PROPRIETORMARTNEFVEXECUT W E OFFICERJMEMSER EXCLUDED? E.L. D15EASE - POLICY UMIT 51,000 000 If eq, deecnbe under SPECIAL PR VISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 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) L4 tKI IF ICAI t: HVLUCK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Lubbock ; DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3d DAYS WRITTEN 1625 13th Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHAtL Lubbock, Tit 79414 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIM! UPON THE INSURER, ITS AGENTS OR REPRESENTATIVE ACORD 25 (2001108) 1 of 3 #M71243 LGM 0 AL•VKIJ L VKI VKAIIi-)T4 tWOO "EXHIBIT 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 negaf¢veiy amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S (2001108) 2 of 3 #M71243 "EXHIBIT A" DESCRIPTIONS (Continued from Page 1} AMS 25.3 (201108) 3 of 3 NM71243 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 Decriptlon Line Total Section 01 -General Requirements 1 01352 0044 HR Investigating Engineer Or Specialty Consultant, Note: Forspecial 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 0210 WK 36" Wide, 1!8 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 1-112 Ton Flat Bed Truck, 4 x 2, With Full -Time Truck DriverNoW 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 314 Ton Light Duty Truck, 4 x 4 Crew PiekupNote- With full-time truck driver 4,344.32 Quantity Unit Price Factor Total Installation 2,00 x 1,769.58 x 1.2275 = 4,344.32 5 01590 0817 EA Bobcat Delivery/Mob/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-SiteWork 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 an CAP -A and CAP -B 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 $2,649.13 22 June 2009 Page 1 of 2 EZIQG Job Order Package 009202.00 10 Sect. Item Mod. UOM Decription Line Total Section 03 -Concrete 8 03640 0003 CF Pressure Injected Cementitious Grout 55,202.43 Quantity Unit Price Factor Total Installation 3,847.00 x 11.69 x 12275 = 55,202.43 143 Cubic Yards of concrete rill Subtotal for 03 -Concrete $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 Ordef Package 009202.00 10 City©f Lubbock Well Plunin2 Project The following five have Brick structures... Footage on building will be about 12'x12'x10'. • Well # 9... 2412 South East Dr. and Ivory Ave. Has pump in Well. Well building built Approximately around 1937. T.D...? • Well # 11.. 3rd 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 41' Casing 18" • Well # 78.. 5014 Ave G. Has pump in Well. In back yard. Well building built approximately around 1952. T.D. 159' Static NIA Casing N/A The Following Fifteen Wells have Steele Well Houses... • Well # 3.. Akon an 2nd 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 NIA • Well # 10.. lit anVernon 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 # 27.. 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 mare 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.... of Drilled Wells aN► MNr AMr Chapter 4 Original Ciround Remove all removable . Pressure Cement from s ,_ hod Bentonite Per gallon or more with .. funnelmarsh r of 50 sec. Or .q w from .gid depth ire Tube r 4 4 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 3831-3536), 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 150th 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 foams on request. The executive director shall prescribe the content of the forms. Resolution No. 2009—R2061 Texas Department of License and Regulation Water Well DrillerlPump Installer Program 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.wellnwithin 30 days following thelicensc.state.tx.us Pgg g lu m ofthe well. PLUGGING REPORT 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. Long. Lat. Grid # 4) Type of Well LJ Water LJ Monitor U Injection LJ De -Watering 5) NT Drill, Pump Installer, or Landowner performing the plugging operations must locate and identify the location ofthe 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. 1111) HISTORICAL DATA ON WELL TO BE PLUGGED (if available) 6) Driller License No. 7) Drilled 1 ! 8) Diameter of hole Inches 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 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 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 Wcll Owner performing the plugging License No. 13) CASING AND CEMENTING DATA. RELATIVE TO THE PLUGGING OPERATIONS, CAS INC LEFT IN WELL DIAMETER inches FROM feet TO feet CEMENTIBENTONITE PLUG($) PLACES TO (feet) IN WELL SACKS FROM (feet) V. 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. 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 I State Zip Lieeand Driller/fump Installer Date I Apptentier I bait TDLR FORM a004W WD It bite - TDLR Yellow - Owner Pink - DrillerlPump Installer