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STATE OF OREGON <br />WATER, SUPPLY WELL REPORT <br /> <br />(1) OWNER: <br />N~m* VINCENT PAVLICEK <br /> <br />Well Nulnb~r <br /> <br /> Aad~2335.~E. MADRONA <br /> '..City CANBY Stat* 0R, ",,, Zip c~7O,1 ~ <br /> (2) 'TypO.. OF, WORK <br /> ["~N~w VCell' ~De~pen~g ~Altera~on (~pair/rec~dldon)~Aban~omnent <br /> (3) DRILLMETHOD: <br /> <br /> (4) PROPOSED USE; <br /> <br />(~) ?Fg0Rg HOLg CONSTRUCTIOn: <br /> <br /> 1/4 <br />Subdivision <br /> <br />(9) LOCAI'ION OFWELL by legal descrlptlo;% County ~A]~TON., Ladmdc <br /> <br /> Section I1 <br /> 'l~x ~t ~Lot Bilk __ <br /> <br /> Swec~ Address of Well (or ncams[ address) <br /> 136~8 PffT,~N ~D ..... <br />(10) STATIC WATER LEVEL: <br /> <br />(11) WATER BEARING ZONES: <br /> <br />Depth at wldch wa:er wa~ first forego ABA~BQI~ <br /> <br />(12) WELL LOG: <br /> Otound Elcva[iun <br /> <br /> llow was se, al placed: Meuhod <br /> [] Other ........ <br /> · Backfill plac~d fr~n , fl, [o,r fl, Material <br /> Gravel plao~d ft~n fl, to fl, $i~ of gravel <br /> (6y~ASINo/L1N~ "' <br /> <br />~9(~ PgRFORATZO~S/SCREgNS: " ' " <br /> ~efforatlons , M~ .MTT,T.g ~NT~E , <br /> ' ~ S~r~, Type Mamrial <br /> <br />, (8) WELLTESTSt Minim. urn testing tln'.~ ls 1 hour <br /> <br />Iht, ' <br /> <br />Temperature of water Depth Ane,Sian Flow Foand <br />Wa~ a walct aoalysis done? ~ Yes By whom <br />Did ~ly s~am.coma~ water not suitable for b~tc~;ded usc? ~ 'lbo fitLle <br /> <br />(bonded) Water Well Constructor Certification: <br /> I a¢¢~pl responsibility for the con;tm¢6on, altetatlon, or ab~d~ment <br />p~do~ on ~is well durMg ~¢ co~stmc~on date~ r¢~a¢d above. All wo~ <br />co ion s~)cd~, TMs rein is tm~ Io ~c bdS[ of my knowledge ~d ~i~f, <br /> ~ _ wwcs~, 688' <br /> <br />Ctmbonded) Water Well Constructor Certification: ' ''- '-~] '" ' <br /> c~Mfy ~at ~e wo~ I pedo~ncd ~ ~e con~tmc~on a~ra~on or abando~n~nt <br /> war is h compliance wi~ Oregon water supply well ~n~cO~ <br /> <br /> WWC Nmnber 1487 <br /> <br />ORIGINAL & FIRST COPY-WATER RF-SOLrECE$ DEPA RTM ENT $ ~'CON f) COPY, CO N gTR LICTCW: <br /> <br /> <br />