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� MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. �County Name � � ' WELL AND BORING CONSTRUCTION RECORD g 18 01� Minnesota Statutes,Chapier 103I Towns ip e Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 118 23 26 S� 5�,,,SF ,,, 231 n 4-13-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude �J Cable Tool ❑Driven �J Auger �Rotary House Number,Sireet Name,City,aruf"ZIP Code of Well Location _ �]pther 725 Si.cih AVe ,�IJrOI�O 55391 DRILLING FLUID WELL HYDROFRACTURED? �;Yes [�Mo Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �ntonite From ft.To ` h. Showing property lines, ; N 1 - i�� (_'r adq s,buildings�ar�i di:ection. USE �No cosmmunity PWS O Monitoring ❑Heating/Cooling ' ; � , _��--�.... /lJ , � Environ.Bore Hole ❑Industry/Commercial [�Community PWS n Irrigation �''�.�Remedial � --J--- ' _�---_:_ �,Elevator ❑Dewatering ❑ ` �`-� w ; ; ; ; e T CASING MATERIAL Drive Shoe? �Yes ❑No HOLE DIAM. � � ' --+--- ' ' -'-%-- hreaded elded . --,-----�-- I �teel �T ❑W ; , � �� ile StiC M a , � ❑Pla ❑ --�--- --;-- ---�----�— • CASING ' ' S ' � Diameter Weight Specifications �1 Mile� � �in.To__�2__ft. Ibs./ft. _�__in.To��`jft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �J��p.To_��ft. Spring Tiill �aolf Cc�ur�e in.To ft. Ibs�fOPEN HOLE in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN 1 725 Sixth Ave N Make Fro�2� ft. To �31 ft. Type Diam. �r�� MN SS391 SIoUGauze Length Set belween tt.and tt. FITTINGS STATIC WATER LEVEL Measured from 1L1V ft. Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME RECEIV�� PUMPING LEVEL(be w land surface) �99 ft.after � hrs.pumping 1}� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION J1�� (1 �7 �� Pitless/adaptermanufacturer��e�t�� Model u �� Casing protection `�f 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump �� `�►TY OF ORONO GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) � Material � rom�_To��_ft. _�__ j]Yds. ags - Matenal��_€��i��_To_'�'�'�ft ❑Yds. �Bags HARDNESS OF Material _From To ft. ❑Yda [J Bags ; GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION C1.$y C�WI'1 1T1@��LilM1 n 1� � feet ,f+� direction _ ��.X..-c type �$ y Cl$� Cay �� 1P �4 Well disinfected upon completion? Yes ❑No ; �-,°CaVf.'IICZA� COWCl flf��tII}I Z�F �7 PUMP 3 }7 CISy bl'S�'1 cedist► b oim snerli 7 �Z J�Not installed Date installed � �" clay �ray ��1� �� (,� Manufacturer's name C a� �r�'Ve eL� ��1' �J 1� Model Number HP 1T�.:� Volts �;ravellrlay Sra� medi►.�n 108 142 �y 7 . —""�� Length of drop pipe ft. Capacity g.p.m , ine sa racan sa.f t 1 2 149 clay •rzy T1Ca�.ti� �(�C� '!(77 Type: Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABA DONED WELLS c sy ray eeft 197 213 gt lttle erJish br aii t i�rC! 213 22� Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE sa stone ahite harc� 22� 2 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,il needed. REMARKS,ELEVATION.SOURCE OF DATA,etc. -I�.lA—�J��GI�s W�-��T1E��A-��Reg�'o. Licensee Business Name i rr � ,� II�7��[) .�L+`� ' .�� "sr-' .._ ,�ert�e'd pres�nta ive Signature � Certified Rep.No. Date ROtJ StOcj0�.8 LOCAL COPY 818 013 Name o,o,��e� -- — - ID#52603 HE-01205-15(Rev.8/13)