<p> 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</p><p>(Please Print)</p><p>Name: License Number: Endorsement: Water Monitor Both</p><p>Our Records Indicate: Changes: Mailing Address: Mailing Address: </p><p>Phone: Phone: </p><p>Email Address: Email Address: </p><p>Employer: Employer: </p><p>Address: Address: </p><p>Business Phone: Business Phone: </p><p>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).</p><p>Renewal Fee Two-year renewal (July 1, 2017 through June 30, 2019) $150.00</p><p>I certify that the information provided on this renewal application is true to the best of my knowledge and belief.</p><p>Signature of Licensee Date</p><p>Return to: Oregon Water Resources Department Attn: Laurie Norton 725 Summer St NE, Suite A Salem OR 97301-1266 (503) 986-0856</p><p>March 2013 Water Well Constructor’s License Renewal/1 WCC</p>