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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Hennepin Minnesota Statutes,Chapter 1031 727744 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 110 23V 32 ,/, y, $4 160 May 18, 2006 <br /> GPS seconds DRILLING METHOD <br /> LOCATION: Latitude degrees minutes <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> ❑ Gl ❑ <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number ❑Auger Rotary Jetted <br /> 7C <br /> 3240 Waterton n Rd, Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Show exact location of well in section grid with"X' Sketch map of well location. rater FROM ft.TO <br /> Showing property lines, <br /> N �;ii` roads and buildings USE ❑Monitoring ❑Heating/Cooling <br /> I Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> t <br /> Noncommunity PWS [__1 irrigation Ll Remedial <br /> 1 L L ❑Community PWS ❑Dewatering ❑ <br /> CASING HOLE DIAM. <br /> W E Drive Shoe? ❑Yes No <br /> _____ ❑Steel ❑Threa ed ❑We ed <br /> ' Mile Plastic <br /> h } 1!4 { t 10 <br /> CASING DIAMETER WEIGHT <br /> S <br /> ,/ - 4 in.to 155 ft. lbs./ft. 81 in.to40 ft. <br /> �1Mile _(. <br /> � riL. (_�.,�,jr� i <br /> in.to ft. lbs./ft. 6} in.to 160 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> Hickory Fine Rome SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make 0 FROM ft. TO ft. <br /> 1844 Wayzata Blvd Type Diam. 51 <br /> PBoa 815 Slot/Gauze 18 Length <br /> Long Lake, MN 55356 Set betweenft.and 160 ft. FITTINGS k packer_ <br /> STATIC WATER LEVEL <br /> 72 ft.41below ❑above land surface Date measured 5-18-06 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below and surface) <br /> Hickory Fine Rome WELL <br /> after hrs.pumping 50+ g.p.m. <br /> WELL HEAD COMPLETION M <br /> Well owner's mailing address if different than property owners address indicated above. }�pltless adapter manufacturer Miss Model 4 <br /> u Casing Protection X 12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes F1 No <br /> Grout material Neat cemeent *Sentonite ❑Concrete E]High Solids Bentonite <br /> from 10 to 40 ft. 3 ❑yds. bags <br /> from to ft. ❑yds. bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. [I bags <br /> MATERIAL <br /> rt NEAREST KNOWN SOURCE OF CONTAMINATION over fron seiner <br /> 0 <br /> clay tan 30 feet direction type <br /> Well disinfected upon completion Yes ❑No <br /> clay gray 30 89 PUMP <br /> ❑Not installed Date installed' <br /> sand 4 gravel gray 89 11A5 Manufacturer's name <br /> clay & sand red 115 146 Model number t ' /t HIP Volts y <br /> Length of drop pipe J ✓ /! ft. Capacity 12 f ) g.p.m. <br /> Type: Submersible ❑L.S.Turbine ❑Reciprocating El Jet <br /> ❑ <br /> sand & gZ1Ye1 mixed 140 16a ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑YesNo <br /> VARIANCE X. <br /> Was a variance granted from the MDH for this well? ❑Yes XNo 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 in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed L <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Stevens Drilling '& Eneirormente.l Svc 86654 <br /> Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Randy Johnson <br /> IC 140-0020 LOCAL COPY <br /> 1727744 Name of Driller <br /> HE-01205-08(Rev.5/02) <br />