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• <br /> •. UNIQUE WELL <br /> WELL OR BORING LOCATION <br /> MINNESOTA DEPARTMENT OF HEALTH MINNESOTAAND BORING NO. <br /> County Name WELL AND BORING RECORD 783515 <br /> : ih Minnesota Statutes,Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 23 3 NESE SW/ 335 h. 7-'284 <br /> GPS Latitude degrees minutes seconds DRILLING METHOD <br /> LOCATION: ❑Cable Tog . ❑Driven ❑Dug <br /> Longitude degrees minutes ' seconds ❑Auger I Rl9otary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ <br /> 2120 Webber Tulle Rd Orono o 55DRILLING FLUID WELL HYDROFRACTURED? ❑Yes .1I-No <br /> Show location of well/boring in section grid with"X." Sketch imap of well/boring location. ��, From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE Cirpomestic ❑Monitoring ❑Heating/Cooling <br /> _ ____i ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> k, ❑Elevator ❑Dewatering ❑ <br /> w - ' E , , * CASING MATERIAL Drive Shoe? Yes ❑No HOLE DIAM. <br /> T O *I Steel ,rThreaded ❑Welded <br /> --'--- I 'k Mite ❑Plastic ❑ <br /> 1.-- 1 CASING <br /> s / <br /> Diameter ,�J/{, J Weight Specifications �''{� <br /> 1 Mile y w ► A J es 4 in.t� ft. lbs./ft. 77/(.t0�5y0ft. <br /> 63/4 <br /> PROPERTY OWNER'S NAME/COMPANY NAME j� in.to ft. lbs./ft ��iin.to�+ ft. <br /> in.to ft. lbs./ft. "•`Ih.to 335ft. <br /> Sargent JEson OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN <br /> Make From 3 ft. To 335 ft. <br /> same Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL Measured from <br /> 90 kik Below ❑Above land surface Date measured 7..20..11 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 250 ft.after hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> ❑Pitless/adapter manufacturer Model <br /> Model <br /> ❑Casing Protection [ieI2 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well , s `F fJi/ f ) <br /> Grout�ma--pals � nt Bent..,t��Concrete I❑Other <br /> rom To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. ❑Yds. ❑Bags <br /> MATERIAL From To ft. ❑Yds. ❑Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> 1 0 / <br /> clay blue mod irapPI) cp-3,, feet direction . }_it .,1,-41jtpq,.. <br /> Well disinfected upon completion? 4es CI No <br /> �..Jl <br /> sand p� 1ti 1,5 PUMP <br /> A d"'J 80 1 J ❑Not installed Date installed 7 21-1l <br /> clay/sand brown *edit 175 200 Manufacturer's name Schuller <br /> Model Number HP 3/4 Volts 230 <br /> rocks 200 205 Length of drop pipe 105 ft. Capacity g.p.m. <br /> Type:A5ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> fine sand brawn soft 235 270 ABANDONED WELLS <br /> sabdstlimi/ white/ <br /> shale �� soft <br /> Does property have any not in use and not sealed well(s)? ❑Yes No <br /> 1 VARIANCE <br /> shale/ blue/ <br /> 3AtIc�BtlfflP Was a variance granted from the MDH for this well? Li Yes +�IVo TN# <br /> mite medium 300 335 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. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling Co., Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> ' !'' 8-16-11 <br /> 3K.d./°#/.; id/ • <br /> iietl Represe tative SigrfaTurey` Certified Rep.No. Date <br /> C + � Stodola <br /> LOCAL COPY 7 8 3 515 Name of Driller <br /> IC 140-0020 '. <br /> HE-01205-12(Rev.12/08) <br />