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VG _LL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD --7 <br /> 1 - 475 <br /> Ekweidn Minnesota Statutes, Chapter 1031 ( i <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> orlow 128 23 32 41-M 188 9-31-04 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> ❑Auger )eotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number ElN� � Rd Orono 55'35 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> 3330 <br /> Show exact location of well in se n grid with"X". Sketch map of well location. =bwFROM ft.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE <br /> .Domestic EnvirEl Monitoring <br /> nBore Hole Industry/Commercial <br /> ---f- <br /> ❑Noncommunity PWS ❑Irrigation ❑Remedial <br /> L ❑Community PWS E]Dewatering ❑ <br /> CASING HOLE DIAM. <br /> w E T Drive Shoe? ❑Yes No <br /> [_1 Steel LlThreaded elded <br /> Mile <br /> '/z (aStiC ❑ <br /> 1 CASING�DIAMETER WEIGHT �{ <br /> s 4 in.to�ft. 2.M 8 ft. <br /> �--t Miley �y`� tf lbs./ft. in.to <br /> in.to ft. lbs./ft. �in.to 288ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Proapeerrttjoowner's mailing address1ffdifferent than well location address indicated above. Make .]L'4brA9011 FROM ft. TO ft. <br /> 3435 Cty Rd 101 Type a�srWegig M♦ Diam. 77 <br /> Mmetotit m, MN 55343 SIoUGauze 0 <br /> 010 Length 1 +41 <br /> �Li1A� Set between ft.and ft. FITTINGS <br /> STAT,CWATEI <br /> an ft.- elow ❑above land surface Date measured &-32-114 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(bel w land surface) <br /> 178 ft.after 1.5 hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION o <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer )._r'^ <br /> ❑Casing Protection )<112 in.above grade <br /> ❑At=grade(Environmental Wells and Boring ONLY) <br /> > ' GROUTING INFORMATION <br /> Well grouted �Yes ❑No <br /> Grout material U Neat cement❑Bentonite <br /> Concretq,,e�igh Solids Bentonite <br /> from,to 30 ft. 2♦5❑yds. Fags <br /> from to ft. I!M ❑bags <br /> GEOLOGICAL MATERIALSCOLOR HARDNESS OF t <br /> FROM TO from o . <br /> MATERIAL ft ❑yds. ❑bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> cla yellow <br /> "ft q® 1 � feet C-0 direction K-A— type <br /> "ft i+� Well disinfected upon completion ❑Yes ❑No <br /> Mid ra soft PUMP 12 18 <br /> Not installed Date installed <br /> soft is <br /> Eli/ Manufacturer's name <br /> 37L/1{. Model number // HP Volts <br /> sand (fine) r soft 120 IM Length of drop pipe /fir lGf ft. Capacity g.p.m. <br /> Type: ubmersible E]L.S.Turbine ❑Reciprocating ❑Jet <br /> watersand 1 ❑ <br /> t) Soft i" ABAN ONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes No <br /> VARIANCE <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,it needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. DIM Stodola % l �*li dao.• *=. 2n72 <br /> Licensee Business Name 1fRyJ. 1 1i/ j *WLi r Reg. <br /> No. <br /> .: ,/6 <br /> ri <br /> G Y <br /> d e he`senIiv&Signat Date <br /> Chuck Mwre <br /> IC 140-0020 LOCAL COPY -7711475 Name of Driller <br /> HE-01205-08(Rev.5/02) <br />