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ir.-Sfadli'&'Sons STATE OF OREGON Well & Pump, Inc. WELL I.D.LABEL#L WATER SUPPLY WELL REPORT 4385 Sta d e l i Lane NE START CARD# 218344 tus required by ORS S37.765&OAR 690-205-0210) (1)LAND OWNER Owner Well LD. Silverton, OR 97381 • °RIGnvALLOG# El First Name Jacob&Ashley Last Name Mueller (9)LOCATION OF WELL(legal description) Company Address 10575 Kaufman Rd NE Apt 6 County MARION g Twp 6 S F N/5 Range 2 W� FJW WM City Silverton State OR Zip 97381 Sec 33 NW 1/4 of the NE �3 1/4 Tax Lot 400 (2)TYPE OF WORK nNew Well ❑Deepening ❑ Conversion Tax Map Number Lot f Alteration(complete 2a&10)lAbandonment(complete 5a) Lat ° "Or DMS or DD (2a)PRE-ALTERATION Long ' "or DMS or DD Dia + From To Gauge Sti Plstc Wld Thrd (i Street address of well ('Nearest address Casing: I I I I I ['_I 0 ❑ 6336 55th Ave NE,Salem,OR 97305 Material From To Amt sacks/lbs Seal:I MI I I I ID . (3)DRILL METHOD (10)STATIC WATER LEVEL Rotary Air ❑Rotary Mud OCable ['Auger OCable Mud Date SWL(psi) + SWL(ft) ['Reverse Rotary ❑Other Existing Well/Pre Alteration 070/9/2021 • 0 Completed Well 07/12/2021 • 0 (4)PROPOSED USE 0 Domestic Irrigation OCommunity Flowing Artesian?❑ Dry Hole? 1111 Olndustrial/Commericial❑Livestock ODewatering WATER BEARING ZONES Depth water was first found ['Thermal Injection 12 Other SWL Date From To Est Flow SWL(psi) + SW!(it) _(5)BORE HOLE CONSTRUCTION Special Standard U(Attach copy) • Depth of Completed Well 0 ft. ■- BORE HOLE SEAL carkc/ I I II Dia From " To Material From To Amt lbs I I I I I 1 Calculated I ®l Calculated (11)WELL LOG Ground Elevation How was seal placed: Method DA OB pC OD DE Material From To ❑Other This was an old hand dug well that had been lined Backfill placed from ft.to IL Material with 6"diameter concrete tiles. Filter pack from ft.to ft.Material Size El We filled with 61 bags of Bentonite hole plug. Explosives used: Yes Type Amount (5a)ABANDONMENT USING UNHYDRATED BENTONITE Proposed Amount P Actual Amount 61 Sacks 0 (6)CASING/LINER . Casing Liner Dia + From To Gauge St1 Plstc Wld Thrd MINN L _ :�_. C • • 0111M CO MO — — mon Amu _, Shoe 0 Inside ❑Outside ❑Other Location of shoe(s) Temp casing❑ycs Din From -i.j To (7)PERFORATIONS/SCREENS Perforations Method Screens Type Material Date Started07/09/2021 Completed 07/12/2021 Peril Casing/Screen Scm/slot Slot #of Tele/ Screen Liner Dia From To width leqgfb slots ine size (anbonded)Water Well Constructor Certification I certify that the work 1 performed on the construction,deepening,alteration,or lam I I abandonment of this well is in compliance with Oregon water supply well CD C:3 construction standards. Materials used and information reported above are true to rn 111 the best ofmy knowledge and belief. EO LZi License Number Date (8)WELL TESTS:Minimum testing time is 1 hour 0 Pump O Bailer 0 Air 0 Flowing Artesian Signed Yield gal/min Drawdown Drill stem/Pump depth Duration(hr) (bonded)Water Well Constructor Certification I accept responsibility for the construction,deepening,alteration,or abandonment work performed on this well during the construction dates reported above. All work performed during this time is in compliance with Oregon water supply well construction standards. This report is true to the best of my knowledge and belief.Temperature °F Lab analysis❑Yes By Water ua iity concerns? DYes(describe below)TDS amount t License Number 87 to Fgrom To Description Amour nits 07/15/2021 i I Signed ,i-12 -- I� Contact Info(optional) IZ ORIGINAL-WATER RESOURCES DEPARTMENT THIS REPORT MUST BE SUBMITTED TO THE WATER RESOURCES DEPARTMENT WITHIN 30 DAYS OF COMPLETION OF WORK Form Version: