Well Information
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Identification
Type of Report: Water Well
Type of Work: ALTERATION
Well Report: POLK 52946 View Log
Well Label: 97867
Start Card: 201613
Original Report:
Owner Well Nbr:
Company Job Nbr:
Primary Use: DOMESTIC
Complete Date: 04/16/2009
Land Owner
Name: JOOST VANDERHAVE
Company:
Address: PO BOX 37

INDEPENDENCE, OR 97351
Location
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Latitude/Longitude
Latitude:
Longitude:
Horiz. Error: ft.
Location
County: POLK
TRSQQ: WM8.00S4.00W9NESE
Tax Map:
Tax Lot:
Lot:
Block:
Subdivision:
Street of Well: 3215 INDEPENDENCE HWY
WM District: 22
Surface Elev:
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Tax Lots

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Well Construction
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Construction
Start Date: 04/16/2009
Completed Date: 04/16/2009
Drill Method: OTHER - NONE
Depth of Completed Well: 38.00
Est. Depth Drilled:
Special Standards:
Seal Placed Method:
Abandonment Start Date:
Abandonment Completed Date:
Backfill
Backfill Placement:
Backfill Material:
Explosives Used:
Explosive Type:
Explosive Amount:
Filter Pack
Filter Pack:
Filter Pack Material:
Filter Pack Size:
Bore Hole
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Seal
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Abandonment Log
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Casing/Liner
Temporary Casing
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Perforations
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Screens
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Well Test
Temperature:
Lab Analysis:
Lab Analysis Done By:
Total Dissolved Solids:
Water Quality Concerns:
Well Test
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Analysis
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Static Water Level
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Static Water Level
Depth First Water:
Pre-Static Water Level: 17.0
Pre-Static Water Level Date: 04/16/2009
Post-Static Water Level:
Post-Static Water Level Date:
Static Water Level
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Materal
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Well Constructor
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Bonded Driller Name: FLOYD G SIPPEL
Bonded Driller Company: SIPPEL WELL DRILLING INC
Bonded Driller Number: 1273
Bonded Date Signed:
Unbonded Name:
Unbonded Company:
Unbonded Number:
Unbonded Date Signed:
Other Name:
Other Affiliation:
Other License Nbr:
Geologist Engineer:
Geologist Date Signed:
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