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. 4 . ., , WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. � : County Name — WELL AND BORING RECORD 6 7 3 8 6 0 - Aen[lepil2 Minnesota Statutes Chapter 103! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � n Orono 117 23 04 ,. ,. ,. 140 I-8-OZ House Number,Stree[Name,City,and Zip Code ot Well Location or Fire Number DRILLING METHOD C Cable Tool 17 riven ❑ Dug 395 Sussea Lane, ��n� 55356 ❑ Auger , Rotary ❑ Jetted Show exact location of well in section grid with"X"�� Sketch map of well location. ❑ _.._____ .__._______._..____.—.. _— Showing property lines, ,_._ rpa s and 6uildings. DRILLWG FLUID WELL HYDROFRACTURED? !,YES O N water i 1 _i i i i_ �. � � FROM r R.to ft. i _i_ _i_ _i ,�e, USE ❑ Monitoring ❑ Heating/Cooling i i i i _�l" �Domestic ❑ Communi PWS _i_ _�_ _�_ _i_ ❑ Irrigation h' ❑ Industry/Commercial i i i i e ❑ Noncommunity PWS ❑ Remedial w e ❑ Environ.Bore Hole i � i i ❑ Dewatering � i � T r '/2Mie � �� a � X F -�{�Q CASING Drive Shoe? ❑ Yes No HOLE DIAM. - - i �,. --- - , i i i ❑ Steel ❑ Th�eaded ❑ Welded i- - �- -i - -, �/ ,t+5 Plastic ❑ s �1 Mile� CASINC�DIAMETER�� VEIC�II � �� PROPERTY OWNER'S NAME �; in.to ft. L��t'� Ibs./ft. in. o/��('�fl. T�� Siden liQ� a� ------in.to----ft. _ _IbsJR �in.�'.`_ft. Property owner's mailing address if different Ihan well location address indicated above. _. __in.[o___ ft. _ _Ibs./ft. in.to ft. 410� Berkst►ire Laae SCREEN`�..L,��e;,� OPENHOLE 7f1 1� IIii T1�7�QutII� MN 5544b Make S«�e� from �_fLto _ft. Type _ � _ .__Diam. SIoVGauze •� Length�-� ♦ � Set between��, tt.and_ 14� tt. FITTINGS:_ 7~X�n~ V�� STATIC�W/A�TER LEVEL `� WELLOWNER'SNAME . ___TSl______—_—ft.�6 below ❑ abovelandsurtace Datemeasured i!$�� PUMPINC�.��(below land surface) •f y C 4 6) Well owner's mailing address if different than property owner's address indicated above. _ ft. after hrs.pumping g.p.m. WELL HEAD COMPLETION }�j �{Pitless adapter manufacturer�±�1 C��a t e� 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�vtateria� C7 Neat cement �� eernonite ❑ Concrete �High Solids Bentonite MATERIAL �to _�. _ 2.5❑ yds.j�bags from_ fill ro�n $Q�t Q f� from__�__to_�_�[ ��}t+� �'fd�i] bags from__._____to._____ft. ❑ yds. ❑ bags £18y r�NII H!@t�itltt! (� 60 Nenr�sr��ewwsouace oF co/prn/nyNgy� � f�--("' �� feet �f/�/� direction f type Well disinfected upon completion? Rf^Yes ❑ No �� f�) G.. � sand rown soft 60 90 pUMP C�ay rev 9drt 40 �20 ❑ Notinstalled Dateinstalled ��'6!'�oG � �' Manutacturer's name A�� i -- �—�----1 @ -----—- '2 Model number_.__ __ HP +a l Volts �+0 sand ray soft i20 140 ��--" - Length of drop pipe.______.____ __ tt. Capaciry ..__ __g.p.m. Type: A� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _______ ABANDONED WELLS 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 p No TN#_ WELL CONTRACTOR CERTIFICATION Use a second sheet,il 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 Stodol8 Well Drilling Co. , Inc. 27 72 Lice e Busines ame � „'� �6.or Reg.No. -`" 3-2b�-�2 - Authorized Represe ive Signature Date Chuck Moore 1-8-02 ----__-- __ Name ol Driller � Date LOCAL C(7PY 6 7 3�6 0 HE-01205-07(Rev.2/99) IC#140-0020