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<br /> MINNESOTA UNIQUE WELL
<br /> WELUBORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. -
<br /> :: CountyName WELL AND BORING RECORD 7 3 ���5�
<br /> Hi.yMA@}�3A Minnesota Statutes,Chapter 1031
<br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED
<br /> 4r.ono 117 23 7 �,, �,, �,, 262 � 6_23-U6
<br /> GPS � DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes___ seconds
<br /> Longitude degrees_, minutes seconds � !Cable Tool f �Driven I I Dug
<br /> - '�. !Auger �otary I I Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number
<br /> � 1305 S'�r�Qe Place Orono DRILLING � � � � �
<br /> � FLUID �WELL HVDROFRACTURED? �..I Yes o
<br /> Show exact location of well/boring in section grid with"X." Sketch map of well location. l✓BntOA�t.e From ft.To ft.
<br /> 55364 Showing property lines,
<br /> N � "� roads,buildings, USE � omestic �.i Monitoring I�!Heating/Cooling
<br /> e and direction. � �.Noncommunity PWS I�I Environ.Bore Hole I.'�.Industry/Commercial
<br /> �' -� ' �--`�� ---�-- j 'i Community PWS ❑Irrigation I.1 Remedial
<br /> ❑Elevator I 1 Dewatering ❑
<br /> - -' � �' � � CASING MATERIAL Drive Shoe? ❑Yes o HOLE DIAM.
<br /> I ; I
<br /> W ; ; ; , E T __ � Threaded I.l Welded
<br /> --�--- --'-----�----'-- � t. �lastlic
<br />� �:. , � ; � ,/z Mile
<br /> � ' � ' r � CASWG �
<br /> --:--- --�--- ----- ------ 1 �., ._._
<br /> Diameter Weight Specifications
<br /> � , S � ,
<br /> �1 Mile� '7 in.to 455 ft.��01 Ibs./ft. V in.to.av ft.
<br /> e ♦
<br /> _in.to ft. IbsJft. _ �in.ta��ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
<br /> Cla tonnFuch� � SCREEN 1/@$ OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated abo e. Make�Q���Q� From _ ff. o�___ ft.
<br /> NOType �_�.6�� Diam.____ p` -__
<br /> Sa�� a8 A��e � � � 2006 Slot/Gauze 'QI Q____ Length _V� _
<br /> ���v Set between�ft.and� fl. FITTINGS�_
<br /> ° OF O�O�O STATI��ATERLEVEL
<br /> ________f�elow . .Above land surface Date measured �$�.m@
<br /> { � PUMPING LEVEL(below land sur(ace) - �� :
<br /> -� WEWBORING OWNER'S NAME/COMPANY NAME ZS3 ft,after Z hrs.pumping 5� a,ir
<br /> ,
<br /> � � '�^.� �� .::__„. .. ..o-:.,,. _�- .;"'. - _ .. -. WELL HEAD COMPLETION � ��{y� '��-^_ �— �--� .
<br /> 9Pm
<br /> a Well/boring owner's mamng aaa�ess i �inerent[han�NwN.,,�y.,.. _.�audress indicated above. �Pitless Adapter Manufacturer v-�h-+�J"i-i-+�-3'"� .
<br /> -- � ---- -
<br /> I �.Casing Protection r'�42 in.above grade
<br /> I �.At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION - -
<br /> � Well grouted? �Yes . No
<br /> Grout materials �_�.Neat cement.�,�entonite Concrete `.�ther__, �`
<br /> From� To���('[��R �f�,�._�1�Yda �[�Bags
<br /> From__t T�:7J ft. ���r�rl'11 �..1'�s��i�Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To__ ft. _�.Yds. . '�.Bags
<br /> MATERIAL
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> . ^ "�r„� s" .. .}
<br /> G"2.d� yelZov �rt~ � �� `�;..''C�' feet � direction' -,:✓'..' ,,�,'�s�..-�a`a"-'[ype
<br /> . Well disinfected upon completion?�Yes C No "`�
<br /> ` C�.i�� graY S � 22 70 PUMP J
<br /> � �Not installed Date installed� tJ ["�`•} � �`�
<br /> saad yray S 70 $� Manufacturer'sname_ '�J��.�v� ��"'_.
<br /> C13y gray S $3 �� ModelNumber HP ���vons ::- � `
<br /> Length of drop pipe ��� ft. Capaciry g.p.m.
<br /> ��11�' Si�Yld brown �,5, 'ZO �O Type:l ubmersible I 1LS.Turbine �..1Reciprocating L.'Jet I�7
<br /> ABANDONED WELLS
<br /> r'
<br /> G Does property have any not in use and not sealed well(s)?�Yes f I No �
<br /> C�$r�e $a11d yray .S �0 VZ VARIANCE
<br /> �� Was a variance granted from the MDH for this well? �.J Yes�No TN#__._,_ •'' _,___ ,�
<br /> WELL CONTRACTOR CERTIFICATION .
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Ghapter 4725.
<br /> The information contained in this report is true to the best of my knowledge. j��,
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<br /> .�� Use a second sheet,il needed. �
<br /> =. REMARKS,ELEVATION,SOURCE OF DATA,etc. arv21 Sta►uOia, �Qll Dri iI f_Q�. CO�� , �
<br /> ---. —_._ —._— . ._. .
<br /> Licensee Business Name � Lic.or Reg.No.
<br /> ` ;��;1� �G�
<br /> o d epresentative Signa e Date
<br /> a
<br /> Chuck M r_
<br /> LOGAL Ct.�NY 7 3 915 4 Name of Driller �grG —
<br /> HE-01205-09(Rev.9/O5)
<br /> � IC 140-0020
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