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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD Towns696476 <br /> „_____in Minnesota Statutes Chapter 1031 <br /> Township Name hip No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 8 y. 'k 204 h. 9-22-03 <br /> GPS Latitude degrees minutes seconds DRILLING METHOD <br /> LOCATION: ❑Cable Tool ❑ riven ❑Dug <br /> Longitude degrees minutes seconds ;❑Auger otary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number ❑ <br /> 847 Tor"m Rds Orow 553% DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Shop exact location of well in section grid with"X". ketch map of well location. pater FROM ft.TO ft. <br /> Showing property lines, <br /> roads and buildings USE <br /> N � E]Monitoring ❑Heating/Cooling <br /> Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> Noncommunity PWS ❑irrigation L]Remedial <br /> --'-----'-----`-----`-- ASING ❑Dewatering _❑ OLE DIAM. <br /> ❑Community PWS ng <br /> I I I �. C Drive Shoe? [ Yes No <br /> W ET 4 <br /> u <br /> ------ - - -- ❑Seel ❑Threaded ❑Welded <br /> Ste <br /> Mile <br /> 1 CASING DIAMETER WEIGHT <br /> "y�.j1 <br /> S t;y �* in.to 1% ft 2.01 lbs./ft. 8 in.to--Wft. <br /> —1 Mile <br /> in.to ft. lbs./ft. in.to2�tt. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in. <br /> in.to ft. lbs./ft. in.to ft. <br /> StonewaW Bni1d SCREEN _ OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make_ FROM ft. TO ft. <br /> 90 Shoreline Dr Type amhqe" Diam. <br /> Spring Park 553M Slot/Gauze • Length <br /> Set between--2;04—ft.and_1% ft. FITTINGS <br /> STATIC WATER LEVEL <br /> 75 ft. below ❑above land surface Date measured 9 .22-03 <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME 1-9A 3 ft.after 3 hrs.pumping 30 71! g p.m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. ❑Pitless adapter manufacturer i*i temater Model <br /> ❑Casing Protection ❑12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION���/// <br /> Well grouted Yes F_No <br /> Grout material ?Neat cement ❑Bentonite El Concrete High Solids Bentonite <br /> from to ft. 3 _ ❑yds. �Xags <br /> from 0 to._J%ft. nQtjr&L fUl ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. ❑bags <br /> MATERIAL <br /> NEAREST-KNOWN SOURCE OF'CONTAMINATION <br /> t r -....� feet direction <br /> e1 11ow soft _ _21Well disinfected upon completion es ❑No <br /> PUMP dR <br /> la :_ soft 2$ <br /> ❑Not installed 7V Date insttalled ___1—_22a_-04___ <br /> fir mid . .. _.-. sof t - ... .._.1 anufacturer's name Aermtnr w /� <br /> 90 Model number HP 1 e 5 Volts_ 230 <br /> 1a soft 150 .- -1 engthof-dreppipe .1.91. ft. Capacity g.p.m. <br /> / <br /> / p �y0 Type:❑.Submersible '�❑L.S.Turbine E]Reciprocating ❑Jet E]ravel - - - bro�nre . .croft _.. :..:143BANDONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes X. <br /> VARIANCE, - - - <br /> Was a variance granted from the MDH for this well? ❑Yes 46o TNri <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,it needed 'f <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stcdola Well AriilU&Co-,-. Itic._ 2nn _ <br /> Licensee Business Name �'O ic.or Reo.No. <br /> 3-31-04 <br /> o d re entative Signatu Date <br /> � 6964761 <br /> hick Moore _S�-22-03 <br /> LOCAL COPY Name of Driller Date <br /> HE-0120508(Rev.5/02) <br /> IC 140-0020 <br />