2017 Water Well Constructor S

Oregon Water Resources Department 2017 Water Well Constructor’s 725 Summer Street NE, Suite A Salem Oregon 97301-1266 (503) 986-0900 www.wrd.state.or.us License Renewal

(Please Print)

Name: License Number: Endorsement: Water Monitor Both

Our Records Indicate: Changes: Mailing Address: Mailing Address:

Phone: Phone:

Email Address: Email Address:

Employer: Employer:

Address: Address:

Business Phone: Business Phone:

Choose Type of License: Bonded License (allows licensee to advertise, offer services, and enter into contracts for the construction, alteration, or abandonment of wells). Unbonded License (licensee may work for bonded Water Well Constructor).

Renewal Fee Two-year renewal (July 1, 2017 through June 30, 2019) $150.00

I certify that the information provided on this renewal application is true to the best of my knowledge and belief.

Signature of Licensee Date

Return to: Oregon Water Resources Department Attn: Laurie Norton 725 Summer St NE, Suite A Salem OR 97301-1266 (503) 986-0856

March 2013 Water Well Constructor’s License Renewal/1 WCC