Report . .,
STATE OF OREGON ‘ -' -l.. . '' VC- co CA.•,) * -:?....LOIRA.S (---(1 , WELL ID#L _None
WATER SUPPLY WELL REPORT
(as required by ORS 537.765) SKYLES DRILLING, INC. START CARD It_wis_20.07
Instructions for completing this report are on the last page of this form
503-8564683
(1)OWNER: well Number:01_ (9)LOCATION OF WELL by legal description:
ceuatY _ .Washington_ _Latitude _ _ Longitude
Nome United.Excamators,.inc/Polygon.Projecl#3_
Address .. Townsliii) 2SOUTH N er S. Range i WEST -6 or W.of WM.
48011.11W_Bethany Blyd,..SteizZEMB.36.1 Section_De sw_ 1/4 sE_ tr4
CitY Roxtiand State OR__ziP 97,229 Tax lot 03200__Lot Block _ _saki:437-0TC
(2)TYPE OF WORK: Street Address ci Well(or nearest address) 13855 BWRoy Ravers_
New Wet :_-Deepening _Alteration(repair/recondition) If‘..Abandonment Rd,.Beaverton,.OR
(3)DRIL (10)STATIC WATER LEVEL: •
L METHOD:
ft.below land surface. Date 905/2011
)t Rotary Air ...',Rotary Mud 7"-Cable [-_-2 Auger Artesian pressure _ lb.per square Inch. Date
_
Other
(11)WATER BEARING ZONES:
(4)PROPOSED USE:
Depth at which water was first found NA., _
X Domestic DCommunity :3 Industrial C Irrigation
•
:mermal 0 Injection :Livestock E Other ,FrrIni. _TP _ ' geliinktad Flow Rate, .AWL
(5)BORE HOLE CONSTRUCTION:
Special Construction approval Yes X No Depth of Completed Well e_
Explosives used 'Yes X No Type _ -
- _. Amount
HOLE SEAL - Ainouii.
Diameter From To Material From To sacks or pounds (12)WELL LOG:
6 ;B_Onto,nite„ _ _; 11,51___42 25 Sacks, Ground elevation
_solculated j_ t ,37 Sacks. Material .:-EGO . To 4.'..Sv_vt,
...__
- I Cam wl_50%benl I 921 37 33$_sc_ko__-____ Aban49"."190t Only ,
. .—_-_, __. .._ , i ___
1 BontOtilitt .,... 374 0 Ilitcka_ I--
-- - Saticolated I ' I-- '23 S_Acts_ r
..........___ ......__ .._
- ------ '--- ,---- - ---- - f- SKYLES DRILLING INC
How was seal placed: Method , A , B _,C ,... 'D CE
X Other Poured,Pumped - - -- "503456-2681
_ ..___
Backfill placed from __ ft.to ft. Material
_
Gravel placed from ft to ft. Size of gravel 1—
(6)CASING/LINER:
Diameter From To Gauge 1 Steel Plastic Welded Threaded RE
Casing:. _ f___-. 0,__.50., _,250.1 Ic 0 rx -
Egising_4___ 70 -5 -
DEC 3 1 2018
_
. . _ 0
. _.:i --, .
CITY 0 ETIGARD
Liner. None.; . -
— BUILDING-ENVISION
:.7 .
-.---
Drive Shoe used .Inside Outside .._,None
. - - —
Final location of shoe(s),buk _ _
-
(7)PERFORATIONS/SCREENS: ---
K Perforations Method AltPerforator
-Screens Type Materiel
. _ .....
Slot Tele/pipe
From To size Number Diameter size Casing Liner
0 . 504118X1 MO FX-
,.,
_
Date started 01i512010 _ Completed gLifiggii
_
(unbonded)Water Well Constructor Certification: •
I certify that the work I performed on the construction,alteration,or abandon-
ment of this wet le in compliance with Oregon water supply well construction
(8)WELL TESTS:Minimum testing time is 1 hour standards.Materials used and information reported above are true to the best of my
Pump 7 Bailer -.Air D Flowing Artesian knowledge and belief.
WWC Number 1004
,.. .0.-_-4,---.0e------
Yield gaVmin Drawdown Drill stem at Time Signed Date 9/18/2015.
Skyles Drilling,Inc.
(bonded)Water Well Constructor Certification:
I accept responsibility for the construction, alteration, or abandonment work
TP.S.A1nount i _14Q PPM performed on this well during the construction dates reported above. All work
._
Temperature of Water _ Depth Artesian Flow found performed during this time is in compliance with Oregon water supply well
Was a water analysis done? 7., Yes By whom . _ construction sta rds. This report is true to the best of my knowledge and belief.
Did any strata contain water not suitable for intended use? ,_-;foo little . - WWC Number 1002
Salty .Muddy --Odor 'Colored Thiher Signed _ t. Date 9/16/2015
_ ...
Depth of strata: Skyles Drilling,Inc.
ORIGINAL-WATER RESOURCES DEPARTMENT FIRST COPY-CONSTRUCTOR SECOND COPY.CUSTOMER
RECEIVEr
DEC 31 2018
CITY OF TIGAHD
BUILDING oIviR
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P.O.BOX 1050
, wEsi GASTON,OR 97110 INVOICE# µ f
503-522-2727
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503-687-2381 FAX _ DATE ..17/1 -
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- YES DAYS_ _ GUARANTEE NO jjf TIME OUT 13 A4
DRAIN NEED FLATHOURLY $ RUTH. �[ PERFORMED DRAIN CLEANING
SURV. HOURLY ■a
ADD DRAINS
MAIN LINE HOURLY T�r 44.f ) t �[q 1. G An k Air DIAGNOSIS FEE
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SEPTIC GAL. ycileil PARTS
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PARTS __ RECOMMENDATIONS
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P.O.BOX 1050
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GASTON,OR 97119 INVOICE#
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S387-2381 FAX
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522-2727 DIPt1315.1_ 51.1 g ay itoprs it dt: _
P„ CITY_Litalotni _ STATE Oitt. ZIP 17/1149
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SURV. HOURLY WORK PERFORMED
ADD DRINCLEANINGAINS .
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MAIN LINE HOURLY &cord pal- iv fo'c 4im k ear DIAGNOSIS FEE
KITCHEN SINK FLAT _ Cinvpuir 4-a t 4 kt- 0 44 fe SEPTIC PUMP tirtlizt-
LAUNDRY LINE FLAT
WATER JETTING
BATH SINK FLAT
VIDEO INSPECTION
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BATH TUB FLAT
LINE LOCATE -
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SHOWER FLAT
EXCAVATION
URINAL FLAT
UkBOR
TOILET FLAT
ROOF/2ND FLOOR
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FLOOR DRAIN FLAT
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AREA DRAIN HOURLY
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RAIN DRAIN HOURLY
. PARTS
SEPTIC GAL. 45etc01
GREASE PUMP
SECOND MAN
APPROVAL CODEX • CHECK#
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PARTS RECOMMENDATIONS
QTY PARTI DESCRIPTION PRICE 0 ENZYME TREATMENT 0 VIDEO INSPECTION
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______.
i i D ROOT KILLER 0 PIPE REPAIR/REPLACEMENT TAX
0 ANNUAL MAINTENANCE 0 CLEANOUT/INSTALLATION TOTAL 'yjo. ta.....•
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PAYMENT RECEIVED
I I 0 WATER JETTING 0 ..,„
--- ,BALANCE DUE i VS0,......77---
ADDITIONA1 TERMS AND CONDITIONS CONTAINED ON 1
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WWWWESTSIDEDRAINANDPI UNWIND COM ACCEPTANCE OF ESTIMATE AND TERMS AND CONDITIONS ACKNOWLEDGMENT OF COMPLETION