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Check No. START CARD NOTICE OF BEGINNING OF WELL CONSTRUCTION ' FIB 3 ~907 (as required by ORS 537.762) MARION COUNTY This form must be completed, signed by b0~h the owner (or authorized agent) and constructor, and the ~IN~iIN~MI~ION delivered to the Water Resources Department, 158 12th St, NE, Salem, OR 97310, no later than the day construction, alteration, conversion or abandonment work begins. A $75 fee shall accompany all notices for new well. construction or conversion of an existing hole not previously used to obtain water (make checks payable to the Water Resources Department). Notices meeting this requirement but received without the required fee will not be accepted as properly and timely filed. In addition, the constructor shall provide the "Watermaster Copy" of this notice to the office of the district watermaster within which the well is being constructed, altered, converted or abandoned using one of the following options: (a)by regular mail no later than three (3) calendar days (72 hours) prior to commencement of work; or, (b) by hand delivery, during regular office hours~ no later than the day work is commenced; or, (c) by FAX no later than the day work is commenced. If method (c) is used, the original "Watermaster copy" of this notice shall also be mailed or delivered to the office of the district watermaster no later than the day work is commenced. The Water Resources Commission has authority to impose civil penalties for failure to submit the required $75 fee with the start · card and for failure to submit cards prior to beginning any construction, alteration, conversion or abandonment work. Owner's name and mailing address: ~ Phone: ~ ~ Check type of work: Fee New construction f [] Alteration (Repair/Recondition) Required Conversion NoFee { [] Deepening ~ Requked I~ Abandonment cO~i~qalumS~rr r Proposed Commencement Date - - or Pa~lxl~d Well Depth t. Q~ ~~ ~ Diameter ~ ~ Domestic [] Public System (Community) [] Industrial [] Irrigation [] Monitoring Check Use! [~ Thermal [] Injection [] Other Proposed Well Location: CoUnty~ Owner's Well Id. No. ~ Township q (~J c~ Range ~ 0g o~ Section ~__ 1. 1/4 of 1/'4 of above section 2. Street address of well location ~ 3. Tax lot number of well location ~ 4. Attach map with location identified. See reverse of this form for approved maps. 5. Show well location within 1/4, 1/4 of section grid at left. We~efe~y c~f'tif74hat we havg rettd the back of this form and that the information provided is accurate to the best of NOTE: This is not a water right applicatiom The owner is responsible for obtaining a water right through the Water Resources Department, if required. The Oregon Health Division requires plans to be submitted and approved prior to construction if the well is to be used as a public system.