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*-WATER SUPPLY WELL REPORT <br /> (a~ ~ulmd by ORS 537.765) <br /> Instructions for completing this report are on the last page of this form. <br /> <br />(I) OWNERn'h · · , t Well Number <br /> <br />(2) TYPE OFWORK <br />~ New~ ~ D~g ~ ~mm~ (m~ir/r~difion)~A~do~t <br />(3) D~LL ~THOD: <br /> <br />(4) PROPOSED USE: <br />~esfe ~mm~ty ~dustfi~ ~gati~ <br /> <br /> ~osiv~rs~ ~Yes ~o Ty~e Amoum <br /> HOLg SEAL <br /> <br />Bae~ Ola~ f~ ft. t6 [ ft., Mate~al <br />Gravel p~ca&T~ ' , ft. ~ ft. Si~ of'g~vel <br /> <br /> Casing: <br /> <br /> [] [] [] [] <br /> [] [] [] [] <br /> <br /> [] [] [] [] <br /> cation of shoe(s) <br /> RFORATIONS/SCREENS: <br />1~.- [~ Perforations Method <br /> [] Screens Type Material <br /> Slot Teletpipe <br /> <br />(8) WELLTESTS: Minimum testing time is 1 hour J <br /> Flowing <br /> [] P~p ~ Bailer ~ Air ~ A~an <br /> Yield Ra~min Drawdown Drilt s~at Time <br /> <br /> r~ <br /> <br />Tem~rature of water ~ ~ Depth Aaesian How Found <br />Was a wat~ analysi~dohe? ~ Yes By whom <br /> <br />(START CARD) # <br /> <br />Did any strata contain water not suitable for intended use? [] Too htfle <br />] ~ ~ -- performed during this time is in cc*'npliance with Oregon water supply well <br />Sahy IIMuddy ~lOdor I [Colored [] Other constmction3t¢mdarff~ This remr[ is tmo to the best of my knowledge and be~ef <br />Dep,ho,,,,.ta: .... '. / O / ' <br /> Signed[ _.~ ~/t~, Date <br />ORIOINAL & HRST COPY-WATER RESOURCES DEPARTMENT sECOND CO?Y-CONSTRUCTOR T~I~D COPY-CUSTOMER <br /> <br /> I accept responsibility for the construction, alteration, or abandonment work <br />performed on this well during the construction dates reported above. All work <br /> <br />(unbonded) Water Well Constructor Certification: <br /> I certify that the work I performed on the constmcrica, alteration, or abandonment <br />of this well is hi compliance with Oregon water supply well construction standards. <br />Materials used and infom~adon reported above are tree to the best of my knowhidge <br />and beIief. <br /> wwc N~n~r /5'8/ <br /> <br />(bonded) Water Well'Constructor~Certillcation: <br /> <br />(11) WATER BEARING ZONES: <br /> <br />Depth at which water was first found <br /> <br />I ~"- F.~ '-' . [: :~ ~l~ <br /> <br />Estimated-Flow Rate SWL <br /> <br />(12) WELL LOG: <br /> Ground Elevation <br /> <br />Material <br /> <br />(9) LOCATION OF ~ELL by legal description: <br /> <br />· Tova~ship ' q : ~ 'o~ge '~, U o~WM <br /> ~on ~ tt4. 114 <br /> Tax ~C~ ~ BI~ ~' S~iv~i~ <br /> <br />(10) STATIC WATER LEVEL: - <br /> ft. ~low l~d ~ ~ <br /> An~ lb. ~ sq~m ~c~ Dam <br /> <br /> <br />