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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO. CcuntyName WELL AND BORING RECORD � g� 4 � 7 ��p� Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono lI8 23 31 �,, ,, ,, 270 n 10-?.�►-03 GPS DRILLING METHOD Latitude degrees minutes seconds LOCATION: �-- �--]Cable Tool ❑D iven ��Dug Longitude __ degrees minutes seconds -r L�Auger � Rotary `.Jetted House Number,Street Name,City.and Zip Code of Well Location or Fire Number r� 4720 Bayside Rd, OrOC1O 55359 DRILLING FLUID WELL HYDROFRACTURED? [,',Yes �` _ o Shop exact location of well in section grid with"X". Sketch map of well iocation. �tVlute FROM ft.TO ft. Showing property lines, _ �: N roads and buildings USE . ❑Monitoring �,!Heating/Cooling ; ; ; ; ; �Domestic ❑Environ.8ore Hole ��_'Industry/Commercial - --'-----J--- '--`— --`-- — — [Noncommunity PWS '_ Irrigation J Remedial �. �Community PWS J��.Dewatering ❑ -- ---- - - --- -- CASING� HOLE DIAM. ' -�--- --�_ � s ;� W E� ,.,�(�� Shoe? .�Ves '�,;��No � ; ,__ ,1�?�Steel �Threade ❑Welded --� ----�— - � ; ; stic , , � � �hI nnua .�,1� — — �Pla �, "-'"-- --'--- --'- ; 1 CASING DIAMETER WEIGHT ,� S t;,.-�^ � � in.to �� ft �� Ibs/ft � in.to_ �—i na�ie---{ �� � � �� in.to ft. Ibs.�ft "• in.to � � PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. ibs.;it. ��`fi.to �� �te A�:1� SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make --- FROM �I' ft. TO ��O ft. - � �s $� Type Diam.___ SIoUGauze Length___ ___ __ Set between tt.and it. FITTINGS STATIC WATER LEVEL � �� ft�,� �� elow [J�above land surface Date measured___.. l��'T� � PUMPING LEVEL(below land surface) WELL OWNER'S NAME/COMPANY NAME '��(} "�"" ft.after_ � hrs.pumping � g.p.m. W LL HEAD COMPLETION �iteaater ,� Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer__.,_._ ___ .____ _ MoSJeI_ ��. �Casing Protection___,___ ._________��12 in.above grade ',�i Ab9rade(Environmental Wells and Boring ONLY) GROUTING INFORMATION � Well grouted �es �r '�.No ,�/ Grout material �_;Neat cemen I.-�Bentonite j Concrete I JKFii h Solids Bentonite r from____ ��to �ft. _ � r__yds. '�__rbags from__ �to��ft. ��ra� �!�� '�__I bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from_ to ft. �yds. ��, I bags MATERIAL --- NEAREST KNOWN SOURCE OF CONTAMINATION ;� ; '� '`�,� � ' C�$� �� r= O �� _ ' .� .� feet ___, direction � �,�1�--�� _type � Well disinfected upon completion Yes �_�.No PUMP ��y r� � i� 1�0 t(��j� ' '�_,,�Not installed Date installed _ . .s" "�� � t *� �� Manufacturer's name___ ��qtQ� y�{ � _... -- —�--�31/ �- 1 Model number __ _.__ �_ Volts ___. C� b�; i� i� �� Length of drop pipe_ /"?�_ _____ft. Capacity g.p.m �l�=gV `_� �� ^� Type:�_,Submersible �LS.Turbir�e __.Reciprocating ❑Jet ❑ ahale/s8ndsta� � `� � ABA DONED WELLS Does property have any not in use and nof sealed v.�ell(s) �JI Yes � �No VARIANCE Was a variance granted from ihe MDH for this well? [��;Yes No TN# WELL CONTRACTOR CERTIFICATION This weli was drilled under my supervision and in accordance with Minnesota Rules,Chap�er 4725. _ The information con�ained in this report is true to the best of my knowledge. � Use a second sheet,i/needed � StQ(�Q�B �11 a�iil� W�� I�. 27172 REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business me Lic.or Reg.Ne. _-_. dre�ve casing 25t3' to 255' f �� � � ,. - -- ---- � , �- _ 11-2�3_ _ Authorized Represen[ative Signature Date cr��oo� zo-a4-o3 _ _-- - ----- _ �9 6 4 8 7 Name o/Driller Date LOCAL COPY HE-01205-08(Rev.S/02) IC 140-0020 -