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Report STATE OF OREGON C C ) if WATER SUPPLY WELL REPORT WF.11,LABEL N LI (a required by ORS 537.763&OAR 690-205-0210) START CARD#(210666 (1)LAND OWNER Owner Well 1.13. (9)LOCATION OF WELL(legal description) First Name Last Name County WASHING" Twp 2 S NS CemPany SPECTRUM DEVELOPMENT CR)REVCONINC, Sec 4 SW 1/4 of the NW 1/4 �TaaxeLot 6200 Address 21420 NW NICHOLAS CT. -- Tax Map Number Lot City HILLSBORO State OR Zip 97124 Lat a 'or DMS or DD (2)TYPE OF WORK New Well❑ ❑Deepening 0 Conversion Long 'or DMS or DD Alteration(repai hccondition) ©Abandonment (47 Street address ofwell C Nearest address DRILL METHOD 1 14235 SW FERN STREET,TIGARD,OR 97223 I X Rotary Air ❑Rotary Mud ❑Cable OAuger OCabie Mud —Reverse Rotary O(hher (10)STATIC WATER LEVEL Date SWL(ps") + S ft (4)PROPOSED USE©Domestic Olmgatlon []Community nti�Well/Predeepeniag 05-30-2014 I I 0� O1ndt,striaV Commencial❑Livestock O e«npietod Well • Ikwateri ❑Thermal ['Injection ❑O Flowing artesian?� Dry Fbk?Other (S)BORE HOLE CONSTRUCTION Special WATER BEARING ZONES Depth water was•• .sad Depth of Completed Well 0 @. Peck Standard Attach copy) swL.Date s..,. I. + ,r BORE HOLE _--_�— ■� SEAL se•kr/ —11111111•1 '� 1=111111— 11_ Din From To Material From To Amt lbs =�I ■- 6 1 0 t 345 SEE#11 45 51 1 S - _ --m :MINI ( I)WELL LOG Ground El How was seal placed. Method O A ©B OC OD ❑E Material ovation attic' From To ABANDONMENT EXISTING 6'WELL(a!345" BackBll placed from ft.to ft. Material INSPECT WELL,PERFORATED CASING(0-7F) Filter pack from ft.to ft.Material Size CEMENT&PEA GRAVEL PLACED IN WELL Explosives used: Dim Type Amount BORE AS SHOWN BELOW (6)CASING/LINER CEMENT(10 SKS) 345 300 asing Liner Du + From To Gauge Sd Piste WId Thrd PEA GRAVEL. 300 p_. 6 0 78 '.250 DIM CEMENT(5 SKS) 250 Aim van. PEA GRAVEL 2255 200) MIMI IMO CEMENT(!!SKS) 200 1811 *MIN �_! I_ PEA EMENT GRAVEL 5 S) 15500 125 Shoe Inside PEA GRAVEL _ 125 100 ❑ ❑Otttstde ❑Other Location of shoe(s) CEMENT(20 SKS) 100 0 Temp casing❑Yes Dia From To (7)PERFORATIONS/SCREENS Perforations Method DRIVE DOWN Screens Type Material STEEL PerfS Casing/Semen Scrnhlo Slot if of Tell creen Liner Dia From To width length slots pipe size Dale Started 05.30.2014 Completed 06-02-2014 Perf ,Casing 6 0 1 78 1 nf4X3 468 ?l re (..beaded)Water Well Constructor Certifeatioa I certify that the work I performed on the construction,deepening,alteration,or abandonment of this well is in compliance with Oregon water supply well construction standards. Materials used and information reported above are true to the best of my knowledge and belief. (8)WELL TESTS:Minimum testing time in I hour License Number 1492 Date 06-02-2014 0 Pump 0 Bader O Air Q Flows...-.ion Password: ding ete 7roni ) M hr Signed m INIONINIII■-= (beaded)Water Well Coastneoa C Nino ---i__ i accept performed on for the construction,deepening alteration,or above. All T wick performed on this well during the construction dates reported about. All work Temperature 'F Lab analys'•Si Yes By performed during this time is in compliance with Oregon wake supply well Water quality concern? -• describe below) construction standards This report u true to the best of my knowledge and belief 1/111.111111112 I.- `: License Number 1266 Dare 06-02.2014 —I == Password:(if(iil' oa..• )- - —_ Signed "' iiii�-- Contact Info(opti. THIS REPORT MUST BE SUBMITTED TO THE WATER RESOURCES DEPARTMENT IN 30 DAYS OF COMPLETION OF WORK Form Version: 0.95 6UP G24)3 —000232 FOR WATER RESOURCES DEPARTMENT USE ONLY Date Postmarked W 210666 Date Hand-Delivered OWRD Receipt Date Region Utlice Recd Date Fee Received Check No. A/4 START CARD NOTICE OF BEGINNING OF WELL CONSTRUCTION (as required by ORS 537.762) This form must he completed and the original mailed or delivered to the region office within which the well is being constructed, converted,altered,deepened,or abandoned using one of the following methods:(a)by regular mail no later than three(3)calendar days (72 hours)prior to commencement of work;(b)by hand delivery,during regular office hours before work is commenced;or(c)by FAX before work is commenced. If method(c)is used,a legible copy of the start card shall also be mailed or delivered to the region office no later than the day work is commenced. The fee required under ORS 537.762(5)for the construction of a new well,deepening of an existing well,conversion of a monitoring well,geotechnical hole,or other hole shall be submitted to the Water Resources Department, 725 Summer Street NE Suite A,Salem,OR 97301-1266 with a duplicate copy of the start card. The Water Resources Commission has authority to impose civil penalties for failure to submit the required$225 fee with the start card,for failure to submit the$225 fee in a timely manner,and for failure to timely submit start cards. t Owner's name: s; Home Phone:( k Mailing Address: ,•r f d r)% i i , Work Phone:( _), City,State Zip ff L L n. - ,, . Type of work: Fee ❑ New Construction No Fee ❑ Alteration(Repair/Recondition) Required: ❑ Conversion Required: T, Abandonment Orig.Start ❑ Deepening Orig.Start Card No. Card No. Proposed Commencement Date: . ,;,f Existing or Proposed Well Depth: Diameter: <. Original Well I.D.Label Number: 4a Use: ❑ Monitoring Do Irrigation ❑ Community(Public System) ❑ Industrial/Commercial ❑ Livestock ❑ Dewatering ❑ Thermal ❑ Injection ❑ Other Proposed Well Location: County Township Range t Section Tax Lot North or South Past or West —" 1/4_... 1/4 Or Latitude Longitude Street Address of well,if not assigned,nearest address: We have read the back of this form and the information provided is accurate to the best of our knowledge. Owner/Agent Name ', Bonded Water Supply Well Constructor Name Liewise No. Date Signed __. Company Date Signed OWNER PLEASE NOTE:This is not a water right application. The owner is responsible for obtaining a water right through the Water Resources Department,if required. The Oregon Health Division requires plans to be submitted and approved prior to construction if the well is to be used as a public system. ADDITIONAL IMPORTANT INFORMATION ON BACK. Revised 07n009 THIS COPY TO CUSTOMER