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f -� WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ,,�,��;�,e WELL AND BORING RECORD 6 6 H O 3 H �'riennepin `�innesota Statutes Chapter f031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed t?rono 117 �� Q� ,, �,, �,. 121 � 1�-20-01 House Number,Street Name,City,and Zip Code o(Well Location or Fire Number DRILLWG METHOD 2601 Raineq Rds Orono 55391 ❑ CableTool [_7 Driven ❑ Dug ❑ Auger �Rotary � ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well loca5on. �1 __ _____________ — .____.- -- -- � Showing property lines, ' �� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ' O N ;::� t�,,_, (�:;, �uper gel-x _i i i �_ � FROM ft.to ft. i_ _i_ 'i_ 'i USE �/ ❑ MoNtoring ❑ Heating/Cooling i i i i �CDomestic ❑ Communit PWS _i_ _�_ _i_ _i_ �� E- Irrigation Y ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w I I I i e T ./3< C Environ.Bore Hole ❑ Dewatering ❑ �Y '� i i i r +�ZIM1e Q CASING Drive Shoe7 ❑ Yes o HOLE DIAM. i � _i_ _i_ � ,,,❑��,,,,,,CCCSteel ❑ Threaded ❑ Welded ' ' � 1 t �lastic ❑ _ '� S �--1 Miie-� CASIN�DIAMETER 113 WEIGHT sdr �1 ! 7/4 � PROPERTY OWNER'S NAME in.to ft. Ibs./ft. '".�° � Patrick/Kirsten Bnrton ;�.to n. ,bs.,h. �;�.,o Property owner's mailing address if different than well location address indicated above. -___—_ in.to ft. Ibs./ft. in.to ft. 16�i17 L�erick Lane SCREEN* OPENHOLE Mictnetonk�, MN 55345 MakeytQ�'itilf0�_ __ from ft.[o _ft. TYPe �t��g� 5��# Diam. -- — � SIoUGauze t A Length -�$ --�-�--- --- Set between ft.and ft. FITTINGS STATIC W/A�TER LEVEL � .��q/� WELL OWNER'S NAME �7,1___._. tt. �below ❑ above land surface Date measured�{-y_L(�' 1 PUMPING LEVEL(below land surface) r Weil owner's mailing address if different than property owner's address indicated above. ___.1�.____ft, after _ 1.5 hrs.pumping 7� g.p.m. �L HEAD COMPLETION Pitless adapter manufacturer_.�j��'P T Model __ ❑ Casing Protection__ �"12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout nnateria� ❑ Neat cement ❑ Bentonite ❑ Concrete �liigh Solids Bentonite MATERIAL from�to_3Q ft. _�_,_.__. ❑ yds.�bags clay yellow soft 0 3.3 from__'�_�o_�_'�tt p$x_�;a_� C�7�Is�� bags from to ft. ❑ yds. ❑ bags CIS OI8p SOf C '�3 g3 NEAREST KNOWN SOURCE OF CONTAMINATION Y O J feet direction type Well disinfected upon completion? Yes ❑ No c2sy/grsvel gr�y soft 93 102 -�--------- PUMP 58�� a�8� �Ot� �Qe� �Z� [7 Notinstalled Dateinstalled �� __ � 1 L Manufacturer's name Aa r�a�A/� Model number_ _.__. HP � Volts__�_ ,_._ . Length of drop pipe 04 ft. Capacity ___ g.p.m. Type: �ubmersible ❑ l.S.Turbine ❑ Reciprocating ❑ Jet ❑ ______ ABANDONED WELLS Does property have any not in use and not sealed well(s)? C! Yes f�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes Qf�No TN# ! WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. Don Stodola WeII Drilling Co., Inc. 2 172 ; � L� see Bus' ss Name � Lic.or Reg.No. __. : �...�.��—. . . -.. � ___ _ - - =-- 8-2'�-02 Authorized Re� entative Signature Date Duane Mathe�s 12-20-UI � --_-. _ — -- Name oI Driller Date �-.�� L�CAL CQPY 6 6 8 0 3 8 HE-01205-07(Rev.2199) IC#140-0020