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CROO 54191

STATE OF OREGON
WATER SUPPLY WELL REPORT

12/29/2014

(as required by ORS 537.765 & OAR 690-205-0210)

WELL I.D. LABEL# L 114180

START CARD # 1021882
ORIGINAL LOG #

(1) LAND OWNER

Owner Well I.D.

First Name
Last Name
Company CITY OF PRINEVILLE
Address 387 N.E. THIRD STREET
State OR
Zip 97754
City PRINEVILLE

(9) LOCATION OF WELL (legal description)

(2) TYPE OF WORK

New Well
Deepening
Conversion
Alteration (complete 2a & 10)
Abandonment(complete 5a)

(2a) PRE-ALTERATION

From

Dia

To

Gauge Stl Plstc Wld Thrd

Casing:
Material

From

To Amt

County CROOK
Twp 15.00 S
E/W WM
N/S Range 15.00 E
Sec 11
1/4 of the
1/4 Tax Lot 300
Tax Map Number
Lot
DMS or DD

'
" or 44.27911111
Lat

'
" or -120.90075000
DMS or DD
Long
Street address of well
Nearest address
AIRPORT ROAD, PRINEVILLE, OREGON

sacks/lbs

Seal:

(10) STATIC WATER LEVEL

Rotary Air

Rotary Mud

Auger

(4) PROPOSED USE

Injection

Irrigation
Dewatering

(5) BORE HOLE CONSTRUCTION

Depth of Completed Well 607.00
BORE HOLE
From
0
482

WATER BEARING ZONES

SWL Date
From

Special Standard

(Attach copy)

ft.

SEAL

Material

To
482
607

Community

Cement w/2% Bentonite

From
0

To
482

Amt
462

1/20/2014
3/3/2014

340
470

SWL(psi)

SWL(ft)
435

Dry Hole?

Depth water was first found 340.00

To

Est Flow SWL(psi)

365
607

Domestic
Livestock
Other

Industrial/ Commericial

Dia
22
17.25

Date
Existing Well / Pre-Alteration
Completed Well
11/28/2014
Flowing Artesian?

Cable Mud

Other

Reverse Rotary

Thermal

Cable

(3) DRILL METHOD

SWL(ft)

200
1200

340
435

sacks/
lbs
S

(11) WELL LOG

How was seal placed:
Other
Backfill placed from
Filter pack from
Yes

Explosives used:

Method

ft. to
ft. to

ft. Material
ft. Material

Type

Size

Amount

(5a) ABANDONMENT USING UNHYDRATED BENTONITE

Actual Amount

Proposed Amount

Casing Liner

Shoe

Dia
18
16
16

Inside

Temp casing

Yes

(6) CASING/LINER

From
2
452
572

Outside

To
482
472
597

Other

Dia

Gauge Stl Plstc Wld Thrd

.375
.375
.375

Ground Elevation 3248.00

From
Road Fill
0
Brown Caliche
3
Hard Gray Basalt
14
Broken Brown and Gray Basalt & Lost Circ
32
Sand & Gravels some brown clay
209
Brown Sandstone
245
Sandstone with Gravel Layer WB
340
Brown Sandstone
365
Broken Basalt, Gravel & Cinders
465
Gray Basalt with Gravel interbeds
515
Brown Sandstone Tuff
545
Hard Gray Basalt
565
Material

To
3
14
32
209
245
340
365
465
515
545
565
607

Location of shoe(s)

From

To

(7) PERFORATIONS/SCREENS
Perforations Method
Screens Type Wire wrap
Perf/ Casing/ Screen
Dia
Screen Liner
To
From
Screen Liner
16
472
572
Screen Liner
14
597
607

Material SS 304L
# of
Tele/
Scrn/slot
Slot
slots pipe size
width
length
.09
16
.09
14

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

Pump
Yield gal/min
780

Bailer
Drawdown
26

Air

Flowing Artesian

Drill stem/Pump depth

575

Duration (hr)
120

F Lab analysis
Yes By Umpqua Labs
Yes (describe below) TDS amount
Water quality concerns?
Amount
From
To
Description

Temperature 56

Units

Date Started 12/23/2013

Completed

5/30/2014

(unbonded) Water Well Constructor Certification

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.
License Number
Date
Signed
(bonded) Water Well Constructor Certification
I accept responsibility for the construction, deepening, alteration, or abandonment
work performed on this well during the construction dates reported above. All work
performed during this time is in compliance with Oregon water supply well
construction standards. This report is true to the best of my knowledge and belief.
License Number 1385

Date 12/29/2014

Signed ROBERT BUCKNER (E-filed)

Contact Info (optional)
ORIGINAL - WATER RESOURCES DEPARTMENT

THIS REPORT MUST BE SUBMITTED TO THE WATER RESOURCES DEPARTMENT WITHIN 30 DAYS OF COMPLETION OF WORK Form Version: