WELL I.D. LABEL# LSTART CARD #

Owner Well I.D.First Name

AddressZip

(1) LAND OWNER

New Well Deepening Abandonment(complete 5a)

Conversion

(3) DRILL METHOD Rotary Air Rotary Mud Cable Auger Cable Mud

OtherReverse Rotary

(4) PROPOSED USE Domestic Community Industrial/ Commericial

Irrigation Livestock Dewatering

StateCity

STATE OF OREGONWATER SUPPLY WELL REPORT(as required by ORS 537.765 & OAR 690-205-0210)

Thermal Injection Other

(5) BORE HOLE CONSTRUCTIONDepth of Completed Well ft.

Explosives used: Yes Type Amount

SEALMaterial From To Amt

OtherBackfill placed from ft. to ft. MaterialFilter pack from ft. to ft. Material

BORE HOLE

(Attach copy)

Dia From To

Special Standard

(6) CASING/LINER Dia

Shoe Inside Outside Location of shoe(s)

From To Gauge Stl Plstc Wld ThrdCasing Liner

(7) PERFORATIONS/SCREENSMethod

Type Material Scrn/slot

widthToFrom# ofslots

Tele/pipe size

Casing/Liner

Dia

(8) WELL TESTS: Minimum testing time is 1 hour

Yield gal/min Drawdown Drill stem/Pump depth Duration (hr)

Temperature F Lab analysis Water quality concerns?

Yes

From Yes (describe below)

To Description

(9) LOCATION OF WELL (legal description)

Tax Lot Lot

Twp Range E/W WMSec 1/4 1/4

Lat ' " or DMS or DDLong ' " or DMS or DD

County N/Sof the

(10) STATIC WATER LEVEL

WATER BEARING ZONESFrom To Est Flow SWL(psi)SWL Date

(11) WELL LOG Ground ElevationMaterial To

CompletedDate Started(unbonded) Water Well Constructor CertificationI certify that the work I performed on the construction, deepening, alteration, orabandonment of this well is in compliance with Oregon water supply wellconstruction standards. Materials used and information reported above are true tothe best of my knowledge and belief.License Number Date

Signed

(bonded) Water Well Constructor Certification

ORIGINAL - WATER RESOURCES DEPARTMENTTHIS REPORT MUST BE SUBMITTED TO THE WATER RESOURCES DEPARTMENT WITHIN 30 DAYS OF COMPLETION OF WORK

Depth water was first found

Temp casing Yes From To

ScreenDia

Other

Tax Map Number

I accept responsibility for the construction, deepening, alteration, or abandonmentwork performed on this well during the construction dates reported above. All workperformed during this time is in compliance with Oregon water supply wellconstruction standards. This report is true to the best of my knowledge and belief.

License Number Date

Signed

Existing Well / Pre-AlterationCompleted Well

From

Company Last Name

E D C B AMethodHow was seal placed:

Perf/Screen

+

Date SWL(psi)

By

Amount Units

sacks/lbs

Slotlength

Perforations Screens

SWL(ft)

+

SWL(ft)

+

Size

Contact Info (optional)

Flowing Artesian?

(2a) PRE-ALTERATION Alteration (complete 2a & 10)

(2) TYPE OF WORK

To sacks/lbsAmtFromMaterial

(5a) ABANDONMENT USING UNHYDRATED BENTONITEProposed Amount

From

+

Dia

TDS amount

Casing:

Seal:

ORIGINAL LOG #

Actual Amount

Street address of well Nearest address

Pump Bailer Air Flowing Artesian

Dry Hole?

Form Version:

ThrdWldPlstcStlGaugeTo

Page 1 of 11141801021882

CITY OF PRINEVILLE387 N.E. THIRD STREET

PRINEVILLE OR 97754

607.00

56 Umpqua Labs

340.00

43511/28/2014

12/23/2013 5/30/2014

1385 12/29/2014

54191CROO

12/29/2014

ROBERT BUCKNER (E-filed)

22 0 48217.25 482 607

Cement w/2% Bentonite 0 482 462 S

18 2 482 .37516 452 472 .37516 572 597 .375

Screen Liner 16 472 572 .09 16Screen Liner 14 597 607 .09 14

Wire wrap SS 304L

31432209245340365465515545565607

1432209245340365465515545565

03

Road FillBrown CalicheHard Gray BasaltBroken Brown and Gray Basalt & Lost CircSand & Gravels some brown clayBrown SandstoneSandstone with Gravel Layer WBBrown SandstoneBroken Basalt, Gravel & CindersGray Basalt with Gravel interbedsBrown Sandstone TuffHard Gray Basalt

CROOK 15.00 S 15.00 E11 300

44.27911111-120.90075000

AIRPORT ROAD, PRINEVILLE, OREGON

3248.00

780 26 575 120

1/20/2014 340 365 200 3403/3/2014 470 607 1200 435