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� MINNESOTA UNIQUE WELL 'rNELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOA/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD g 18 0 41 ` F�ermepin Minnesota Statutes,Chapier 10.3I ; Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 118 23 29 SW,,SE ,, 1 G� K 7-5-I6 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven �Auger �'Rotary House Number,Sheet Name,Ciry,and ZIP Code of Well Location ❑Other 35�i5 Sixth Ave Ns vLO�K� 5535b DRILLING FLUID WELL HYDROFRACTURED? ❑Yes '�No - Show exact location of well/boring in section grid with"X" Sketch map of well/ oring locatio (�t�[ From ft.To ft. Show roper ' s, ��;. N roa�di rection. USE io/Domestic `Monitoring ❑Heating/Cooling , � �� ^: __;_____j___ ___!__ ___�__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Indushy/Commercial � _ ❑Community PWS ❑Irrigation I J Remedial c --'--- --;--- --F-- ---t-- 'r�.�} ❑Elevator ❑Dewaterin9 :J � ' w ; ; ; ; E� + CASING MATERIAL Drive Shoe? ❑Yes ,�'No HOLE DIAM. --;--- --�-----�-- --�-- J' : , , � � Threaded ❑Welded �� , , , , ile Steel �, � , , , , �� lastic ❑ . ; --�--- --�--- ---�-----�- l -�� ; ; ; ; � CASING S Diameter Weight Specifications �—t Mile--� `+ in.To 1� ft. Ibs./ft. in.To__��tt. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. _�_in.T��ft. Rick .Anderson in.Ta ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE IW t�A�y�CI� Rd Make � From ft. To ft. s [I�l �LC1� '�I 553�►3 Type stainleaa RtPP� Diam. - � SIoVGauze �1(1 Ler�tll� / � Set between ft.and it. FITTINGS ! STATIC WATER LEVEL �+ Measured from 1 73 ft. Below ❑Above land surface Date measured �S�i6 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surtace) 1�� ft.after � hrs.pumping 30 g.p.m. ; Well/boring owner's mailing address if different than propert i t above. WELLHEAD COMPLETION �itevaater Pitless/adapter manufacturer Model FEB ? � ��17 �Casing protection _�12 in.above grade �At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Cll'Y OF ORONO Material[I�EItCMlte From�To��ft. _�_ ❑Yds. '�ags Matenal[Ifi'�t7CR� f'��r�_..S�To��_ft. U Yds. [i Bags HARDNESS OF Matenal _From To ft. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION „ C..�` a � ,^� feet `+�-� direction ' �„,l-f'�4 type a Well disintected upon completion? Yes [J No PUMP 1 Not installed Date installed 11-7-16 ` �Y Manufacturer's name ��€e�_— Model Number HP��f}_Volts� � Length of drop pipe �.0� ft. Capacity g.p.m � Type: Submersible ❑LS.Turbine ❑Reciprocating L,�Jet ❑ ABANDONED WELLS Does properry 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,Chapte�4725. The information contained in ihis report is true to the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. � SL��$ �11 Drillin�+; Co,. J,�:. 1b92 Licensee Business Name Lic.or Reg.No. , r ' - iz-i2-l� � e � ntati '� atu Certified Rep.No. Date .�3 � LOCAL COPY ROb Stodol� 818 0 41 Name of Driller ID#52603 HE-01205-15(Rev.8/13) P �.