Attachment J04 Well log and water test result.pdf

STATE OF OREGON

WATER SUPPLY WELL REPORT WELL I.D 74716

as required by ORS 537765 START CARD 169175

Instructions for completing this report are on the last page of this form

OWNER Well Number__________ LOCATION OF WELL by legal description

Name Jessica Justin Mathlson County Douglas Latitude Longitude___________

Address 1792 SE Hamilton Stret Township 26 Range WM

City Roseburg State OR Zip 97470 Section 16 SE 1/4 NE 1/4

TYPE OF WORK Tax Lot 1100 Lot_______ Block_______ Subdivision_________

New Well Deepenmg Alteration repair/recondition Abandonment Street Address of Well or nearest address 1340 Brozio Road

DRILL METHOD Roseburg OR

Rotary Air LiRotary Mud LiCable LiAuger 10 STATIC WATER LEVEL

LiOther 71 ft below land surface Date 1017/04

PROPOSED USE Artesian pressure lb per square inch Date ___________

Domestic Community Industrial Li Irrigation 11 WATER BEARING ZONES

Injection Li Other

BORE HOLE CONSTRUCTION Depth at which water was first found 88 ft

Special Construction approval No Depth of Completed Well 285 ft

Explosives used LiYes No Type __________ Amount

From To Estimated Flow Rate SWL

HOLE SEAL 88 89 1/2 71

Diameter From To Material From To Sacks or pounds 274 276 85 71

10 19 Bentonite 19 sacks

19 285

12 WELL LOG

How was seal placed Method LB LiC Ground Elevation _________________________________

Other poured dry ___________________________ _____ _____ _____ Backfill placed from ft to ft Material____________ Material From To SWL

Gravel placed from ft to ft Size of gravel _________ Brown clay ______

CASING/LINER Shale _____ Diameter From To Gauge Steel Plastic Welded Threaded Course sandstone hard 33

Casing 19 .250 LI Li Li Course sandstone med hard 33 274 71

________ Li LI Li LI Course sandstone broken 274 276 71

________ Li Li LI LI Course sandstone hard 276 285

____Li Li LI LI ___________ __ __ __ Liner 285 Li Li Li __________________ ___ ___ ___

____Li Li Li Li ___________ __ __ __ Final location of shoes 19 ft _____________________________________ _______ _______ _______

PERFORATIONS/SCREENS ________________________ _____ ____ ____

Perforations Method saw cut ___________________________________ _______ ______ ______

Li Screens Type _____________ Material

Slot Tcie/pipe

From To size Number Diameter size Casing Liner

175 275 .1 Li ________________________________ ______ ______ ______

____ ____ Li Li _________ __ __ __ ____ ____ Li Li __________ __ __ __ ____ _____ Li Li __________ __ __ _____ ____ Li Li _________ __ __ __

WELL TESTS Mlnhnuin testing time Is hour Date started 10/6/04 Completed 10/7/04

Flowing unbonded Water Well Constructor Certification

Li Pump Li Bailer Aer Li Artesian certi1r that the work performed on the construction alteration or abandonment of this well is in compliance with Oregon water supply well construction standards Yield gal/mm Drawdown Drill stem at Time

Materials used and information reported above are true to the best of my knowledge

85 280 hr and belief

___________________ _____________________ WWC Number________

Signed Date

Temperature of water 49 Depth Artesian Flow Found ___________ bonded Water Well Constructor Certification

Was water analysis done Li Yes By whom________________________ accept responsibility for the construction alteration or abandonment work

Did any strata contain water not suitable for intended use Li Too little

Li Salty Li Muddy Li Odor Li Colored Li Other ________________ construe on stan are is the best of my knowledge and belief

Depth of strata

Signed

WWC

Numerl

ORIGINAL FIRST COPY-WATER RESOURCES DEPARTMENT SECOND COPNST OR RD COPY-CUSTOMER