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MINNESOTA UNIQUE WELL OR�'►�RING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD g 2 6 6 61 Necmepin Minnesota Statutes,Chapfer 1Q3I Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED _ �C'ex�0 117 � 23 1Q I�W SE I�IE r � �� 33Q "� 1 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool [I Driven ��Dual Rotary ^ L]Auger �Rotary [.�Rotasonic - House Number,Street Name,City,and ZIP Code of Well Location ❑Other I76fl Shoreline �r� �rQYId DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �ent{��Ce From ft.To ft. c � � roperty lin , � , roads,buildings, d direcf USE ; N � Domestic ❑Monitoring ❑Heating/Cooling _ ,__ ._,___ �_ __;_ ❑Noncommunity PWS �Environ.Bore Hole ❑Industry/Commercial ' �]Community PWS ❑Irrigation j]Remedial -- - -- � �]Elevator ❑Dewatering ❑ ". '�'� ' ; ; E T CASING MATEAIAL Drive Shoe? �Yes ❑No HOLE DIAM. - - �--- -�-----�— '- �-- I : - �Steel �Threaded n Welded s. ; , , , /z Mile , , , , II ❑Plastic �] - '-----,----�- ---�- 1 � CASING S � Diam/�eter Weight Speci(ications �--i M;ie—� `'� in.To ��ft. Ibs./ft. � in.To �� ,>:�r_,�,�.Q,;�,....�e.. �.�. . ► 37 f� 3 �. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. iK.To �. .. �+Lr��(m� I�.+• in.To ft. Ibs./tt. in.To ft. Property owner's mailing address if different than well location address indicated above. p SCREEN OPEN HOLE 7iN'1 c`�st i.KLke w7''�� /►.213 Make From �O� fl. To �� ft. . �� ��Z$t8� ��t 553912 Type Diam. ; SIoUGauze Length s Set between_ ft.and ft. FITTINGS ' STATIC WATER LE1VEL1 f Below �-�Above land surface Measured from_�1-l�asured _Dry hole ❑ Yes No WELL OWNER'S NAME/COMPANY NAME pUMPING LEVEL(below land surface)L �� ft.after v hrs.pumping � _g.p.m. '. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t7L.=��$�er i Pitless/adapter manufacturer Y¢111 ,_ Model °� i ❑Casing protection__ �12 in.above grade ❑Abgrade ❑Well House [J Hand Pump � GROUT W FORMATION(specify benronite,cement-sand,neat-cement,concrete,cuttings,or other) Material�t�ite From v To 2$5 n. 18 �Yds. �Bags Matenal From To ft. �Yda ��Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Matenal From To ft. ❑Yds. ��Bags MATERIAL Driven casing seal From GDD To zss _Bags �ne bag=94 Ibs.cement or 50 Ibs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION clay/sarid brotm meditan 0 19 � ^� -- �' -- Well is_. .1_ l.�---._ __feet . _ �_ _ ___direction from�� -� type — �---- Well disinfected upon completion? �Yes ❑No cl�y/sarxl gray med.i�an I9 131 PUMP s�ridy clay/�rave ced medi�n 131 260 °"°"�S`a°ed Date installed �� Manufacturer's name sLHIl� ('�(� y�rd �� fLo Model Number HP 1.5 Volts L Sri G174? L Length of drop pipe 12`j ft. Capacity g.p.m g�1$1e�9��E�T1� �it� �f� 2`Jil 2p5 Type: Submersible ❑LS.Turbine ❑Reciprocating f�Jet I� ABANDONED WELLS L�e} shalelsandstone ��te 1 e2ird 2�� 3� Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. � The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. ��C�IVED T�on Stcx3ola �Tell I�rillin�g Co, znc. 1�91 Licensee Business Name Lic.or Reg.No. APR ± � 201� .� '�" 1-17-18 CITY OF ORONO C ifiecl Representative Signature Certified Rep.No Date k ; R.(3h StOC1018 LOCAL COPY 8 2 6 6 61 Name of Driller � ID ri52603 HE-01205-16(Rev.5/16)