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NOTICE To WATER WELL Coll The original and first copy WELL REPORT of this report ale to be r filed with the OY' OIaEGON E STATE ENGMEER, SALEM, OR A7 7971 fl."tvne or Drint) within 30 days from the d q~ i of well completion. i ! Zi (1) OWNER: Name f•~ _ Address I J~ls Fs, !5 (2) TYPE OF WORD (check): New Well tg Deepening ❑ Reconditioning ❑ Ahandon ❑ >f abandonment, describe material and p[ocedure in Item 12. (3) TYPE OF _WELL: (4) PROPOSED USE (check): Rotary 0 Driven ❑ Domestic / Industrial ❑ Municipal ❑ Cable Jetted Dug ❑ Bored irrigation ❑ Test Well ❑__Other ❑ CASING INSTALLED: Threaded ❑ , Welded Diam. from ft. to ft. Gage ....__.-.J _._S._...' Diam, from f.'....._Y_......_ it. to .1.._./.. ft. Gage /Y___..... Diam. from ft. to ft.. Gage PERFORATIONS: Perforated? Yes ❑ No. Type of perforator used n J9j12W Size of perforations _An. by Y in.N ._...,.jr...u perforations from ......J.?........... _ ft. to - ft. perforations from ft. to........ _ _._:..::_........it. perforations from ft: to ft.. (7) SCREENS: Well screen installed? ❑ Yes _ }F( No Manufacturer's Name - - Type _ Model No.....__......._.:..__:__.... Diam..... Slot size Set from it. to _ ft. Diam. Slot size Set from ft. to ft. (g) WELL TESTS: Drawdown is amount water level is lowered below static level Was a pump test made? ❑ Yes Dd No If yes, by whom? Yield: gal./min. with it. drawdown after hit. n n p 7•S" gal./min. withAIA Vft. drawdown after J hrs. Artesian flow g.p.m. nerature of water . Depth artesian flow encountered it. low- (9) CONSTRUCTION: /y 1r Well seal-Material used - .L_!_!L?.........._!r .Q...~-_............... Well sealed from'land surface to L 34.. ft. Diameter of well bore to bottom of. seal /..,-1....,-" in. 7 .37 Diameter of well bore below seal _4 in. - Number of sacks of cement used in well seal ......_..4 sacks i Number of sacks of bentonite used in well seal sacks Brand name of bentonite _ _ Number of pounds of bentonite per 100 gallons of water _ _ _ lbs./100 gals. Was a drive shoe used? ❑ Yes No Plugs _ Size: location ft. Did any strata contain unusable water? ❑ Yes No Type of water? depth of strata Method of sealing strata off Was well gravel packed? ❑ Yes No Size of gravel: Gravel placed from ft. to ft. ite above this line) State Well No. 53 ~ State Permit No._ (10) LOCATION OF WELL: County 44 /YE Driller's well number ?a ?'s Section T. )Rd R. {v 1" W.IVL , Bearing and distapge'from sectfUi or subdivision -coiner (11) WATER LEVEL: Completed) well. Depth at which water was first found y p it. Static level ~I ft. below land surface. Date ~Q_74 Artesian pressure per square inch. Date WELL LOO: / (12) Diameter of. well below casing Depth drilled 69 it. Depth of completed well S ft. Formation: Describe color, te?ctui-e,'grain ,size and structure of. materials; . and show thickness and nature of each stratum and aquifer enetrated, with at least one entry for each change of formation. Report. each change in position of Static Water Level and indicate principal water-bearing strata. Work started - 19 © Completed S~ 2eq 1979P Date well drilling machine moved off of Well 19 7e7 Drilling Machine Operator's Certification: This well was construcfeil under my direct .supervision.- Materials used and information reported above are true to my best knowledge nd belief. - [Signedl aa ' ' T C Date f~ ~a 197 _ ~rillin8 Machine er or Drilli g' _Machine Operator's'License No. Water Well Contractor's Certification: This well was drilled under my jurisdiction and this report is . true to the,(best rof my knowledge and belief. Nanle 10farli,.c_l._..... (Person, or corporation) (Type or prinAddress ~Ulr'£~Y . [Signed] . ,(Water Well Contractor's License No. F.7.._ Date 19 MATE.B.IAL From To SWL e,(, 4,V d111 ZAC16 /m .o !v ri,~F . UE J Q lU ova E.PS 3 ~WZI 10P s 3 eZA.y S i14 6&' (USE ADDITIONAL SHEETS IF NECESSARY) g2•4ssWAU