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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORDRefaidAn <br /> Minnesota Statutes,Chapter 1031 705902 <br /> Township Name 7`117 <br /> hip No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 2 06 � 170 12-18-03 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool F]Auger Jetted <br /> oX <br /> rtary iven ❑Dug <br /> ❑ <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number 1:1 <br /> 473 Tonkm a Rd 553% DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Show exact location of well in section grid with"X". �}, Sketch map of we location. sled' FROM ft.TO ft. <br /> 0 Showing pro rty lines, <br /> N roads an bulbs USE <br /> ❑Monitoring ❑Heating/Cooling <br /> Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> Noncommunity PWS ❑Irrigation ❑Remedial <br /> ❑Community PWS ❑Dewatering ❑ <br /> --i-----r----`-----`-- OLE <br /> CASING DIAM <br /> W e T Drive Shoe? ❑Yes o <br /> I ❑Steel ❑Threaded ❑ Ided <br /> _ 'h Mlle <br /> 1 Plastic ❑ <br /> ` CASIN DIAMETER WEIGHT '�(� <br /> F--t Mile--i J\ 4 in.to 163 ft. 2.M lbs./ft. 8 in.to Oft. <br /> _ fff n.to ft. lbs./ft. in.to 1•0 <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> Dmm Fritz SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make B1~ FROM ft. TO _ft. <br /> Type PC Diam. <br /> Slot/Gauze 0w Length 71 <br /> Set between ft.and ft. FITTINGS _ <br /> STATICWATE L EL i � <br /> imft. elow ❑above land surface Date measured 12-18-03 <br /> WELL OWNER'S NAME/COMPANY NAME <br /> PUMPING LEVEL(bel6w land surface) <br /> Is <br /> 160 ft.after Z hrs.pumping 1S g.p.m. <br /> WELL HEAD COMPLETION �,y, <br /> Well owner's mailing address if different than property owners address indicated above. itless adapter manufacturer lfttMtef Model <br /> Casing Protection [K2 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION����rrrr <br /> Well grouted s F1No <br /> Grout material Neat cement <br /> [-]Bentonite LlConcrete Fligh Solids Bentonite <br /> c from 0 to 30 ft. 3 <br /> ❑ <br /> +� ,�1 yds. bags <br /> from to ft. 10tUC�1 ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. <br /> MATERIAL ❑yds. ❑bags <br /> soft <br /> KNOWN SOURCE OF CONTAMINATION <br /> clay yellow soft 0 16 feet --- direction type' <br /> Well disinfected upon completiones ❑No <br /> clay gray soft 16 W PUMP <br /> ❑Not installed Date installed 12-19-03 <br /> sand/gravel bram soft 60 120 Manufacturer's name Aermater <br /> sandgrAj► 1 sol t '120 17 IP Model number �t HVolts 230 <br /> Length of drop pipe 166 ft. Capacity g.p.m. <br /> Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABA14DONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yeso <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes X0 TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained inthisreport is true to the best of my knowledge. <br /> Use a second sheet,if needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. DontDrilling3todola elDrillingclos,, Itm. 27172 <br /> Licensee Business Na Lic.or Re .No. <br /> C-51w, r Z", _;_4 — 12-30-03 <br /> /Z/Xi <br /> A ri r sentative Sig atur Date <br /> ClyaWbore SINX9111151M 12-18-03 <br /> Name o/Driller <br /> LOCAL COPY � 705902 HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />