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ESOTA UNIQUE <br /> WILLR E&gING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORING NO.WELL <br /> County Name WELL AND BORING RECORD 06 21 <br /> Hennepin Minnesota Statutes,Chapter 1037 <br /> Township Name Township No. Range No. Section No. Fraction WELL/QORING DEPTH(completed) JDATI <br /> WORK COMPLETED <br /> Orono 117 23 04 123 5-3-07 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool E]Driven Dug <br /> ❑Auger Rotary ❑Jetted <br /> House Number,Street Name,Ciry,and Zip Code of Well Location �or Fire Number r-1305 Willow Dr S. Orono 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Show exact location of well/boring in section grid with"X.' Sketch map of well/boring ication. Inter From ft.To ft. <br /> Showing prope lines, <br /> N roads,buildings,and d 9 Qn. USE Domestic El Monitoring [IHeating/Cooling <br /> �r� Y ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> --'-----�------F-----1-- \� ❑Elevator ❑Dewatering ❑ <br /> w E N.__.,_ CASING MATERIAL Drive Shoe? ❑Yes No OLE DIAM. <br /> T C GMAT L H <br /> �• ❑Steel ❑Threaded ❑Welded <br /> h Mile Plastic ❑ <br /> 1 � CASING <br /> s t `.`} Diameter Weight Specifications <br /> 1 Mile 1 in.to 115 ft. 2-M lbs./R 8Stm 8 in.to 30 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. —lbs./ft. 6k in.tol23 ft. <br /> ChriS/(Ann .Stariiah in.to ft. lbs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> same as above Make JobrMM <br /> t From ft. To ft. <br /> Type stainless stl ----Diann. <br /> Slot/Gauze .010 Length 41 f 49 <br /> Set between ft.and=1.1 r FITTINGS N w <br /> STATIC WATER LEVEL <br /> Measured from <br /> c <br /> j ft.?(Below F]Above land surface Date measured�� <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)) <br /> 114 ft.after 1.4 hrs.pumping 30 9-p m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t, } <br /> Pitless/adapter manufacturerh-� <br /> ❑Casing Protection 12 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATI N <br /> Well grouted Yes ❑No <br /> Grout materials ❑Neat cement Bentonite ❑Concrete ❑Other <br /> From_To--30—ft- 3 ❑Yds. Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From30To 1'!! ft.jW '�s. ❑Bags <br /> MATERIAL STT <br /> From To ft. ❑Yds. ❑Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> topsoil black soft 0 3 /yJ feet E� direction —type:_-�! <br /> S Well disinfected upon completion? Yes ❑No ti <br /> Clay gray ft 3 30 PUMP <br /> r,t w_�,,� V �[�} ❑Not installed Date installed <br /> - y " <br /> line Ali[ 9EMJ soft 60 Manufacturer's name <br /> clay/sand gray pit, > i 11 Model Number ` HP�Volts <br /> Length of drop pipe �✓ ' ft. Capacity g.p.m. <br /> sand brmn 12 Soft ! 123 Type: Submersible ❑L.S.Turbine ❑Reciprocating []jet ❑ <br /> 1 11 GJ ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes 5jeNo <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 /> Use a second sheet,if needed. <br /> The information contained in this report is true to the best of my knowledge. <br /> � �/ om, <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well �1�.iE� Co..WIm. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> 2550�e ent a Signatu Certified Rep.No. Date <br /> LOCAL COPY F750621 �k Mooce <br /> Name of Driller <br /> IC 140-0020 HE-01205-10(Rev.6/06) <br />