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_ � <br /> _ , <br /> } � _. <br /> � MINNESOTA UNIQUE WELL <br /> WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> CountyName WELL AND �ORING RECORD -�.. .7 3 91 3 H <br /> Minnesota Statutes,Chapter 103I ; <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK�COMPLETED <br /> R. <br /> '/. '/a '/.�;. <br /> GPS -' DRILLING METHOD <br /> LOCATION: Latitude__ degrees _ minutes seconds <br /> �. .Cable Tool I I Driven �..._.Dug <br /> Longi[ude.__ degrees__ minutes seconds I '�.Auger �(Rotary �. �.Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number I I <br /> 1� B� ISZA�� OrOL1O ``DRILLINGFLUID WELLHYDROFRACTURED? CYes No <br /> Show exact location of well/boring in section grid with"X." ��^`^�map of well location;���.. ��� <br /> From fL To ft. � <br /> ��- � owing property lines, � <br /> N .p� roads,buildings, USE Domestic �.Monitoring '. I Heating/Cooling <br /> � � � � y� and direction. � °�, �Noncommunity PWS � ,Environ.Bore Hole � ;Industry/Commercial <br /> --'--- --'--- --`-- --'— � �'. <br /> Community PWS I I Irrigation i �.Remedial �r <br /> �.Elevator I 1 Dewatering �ti� <br /> ' ' ' � CASING MATERIAL Drive Shoe? ���Yes ' No HOI.�DIAM. ��� <br /> W � � � � E T eel � hreaded ' Welded � <br /> . <br /> , , , 1 St __�T _ <br /> , <br /> , , , . <br /> --•--- --'--- --�-- ---`— <br /> � Plastic �. <br /> '/z Mile <br /> I ! I ! _ � CASING . � <br /> --,--- —,------^-----r- <br /> � Dialneter 135 We�hto� Specifications � �n <br /> S �� � Jv <br /> �—1 Mile--{ �ys in.to ft. Ibs./ft. in.t ft. <br /> V T �a'M in to ft IbsJft � in.t�ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> City of Orono SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make Johnson From ft.To ft. <br /> r•0• 1�Vx 6� � Type SCBItll�s$ Stl � Diam. 2� <br /> . t.��7.gt$1 1XSy� MH[�11 55323 Slot/Gauze_;�1�_ _ Length �t � �� <br /> Set between ft.and ft. FITTINGS � � <br /> STATIC WATER LEVEL <br /> 5J ft.�Below I Above land surface Date measured_ P-1-1J6 <br /> ^ . . PUMPING LEVEL(below land surface) <br /> WEWBORING OWNER'S"NAME/COMPANY NAME . , "' <br /> � - '�� � � � � ft.aftei` __.2.5 hrs.pumping 1{5 g.p.m. <br /> WELL HEAD COMPLETION .� ,. <br /> Well/boring owner's mailing address if different ihan property owner'�address indicated above. I. I Pitless Adapter Manufacturer Model <br /> -I Casing Protection IK1�2 iTn.above de <br /> ���At-grade(Environmental Well and Boring ONLY) a�1 se��� <br /> GROUTING INFORMATION <br /> Well grouted? �iYes i�No <br /> Grout materials I�I Neat cement�8entonite .Concrete C�'.Other__ _ �/ <br /> From�To.__�R 3.5 . .Yds. �5 Bags <br /> From_��To 1�5 ft. ����_� h�'�c�.l I�..;Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. '�. i Yds. I I Ba s <br /> MATERIAL 9 <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> (.'l�jy br�{�Tjj g�f t Q 'L'L �O feet � direction��� ryPe <br /> . Well disinfected upon completion? Yes ❑No <br /> sand/gravel brown soft ZZ � PUMP <br /> . Not installed Date installed (T7—W <br /> clay/cocks gray medium 6Q 120 <br /> Manufacturer's name �r�t�r <br /> Model Number HP � Volts �� <br /> .4�� gray .��ft �GO 1�3 Length of drop pipe 1�5 ft. Capacity g.p.m. <br /> Type�Submersible '..LS.Turbine LJ Reciprocating f l Jet I I � <br /> ABANDONED WELLS ' <br /> Does property have any not in use�and not sealed well(s)? C Yes�tvo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? -'Yes�jNo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> � This well was drilled under my supervision and in accordance with Minnesota Rules,Chap[er 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,il needed. y <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. � St�O1S YYell DL11I1TIg W�� Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> � I2-1�-Q6 <br /> . r p sentati Signat � � Date <br /> Chuck I�oore <br /> IMPORTANT-FILE WITH PRUPEf37""Y PAPFRS 7 3 913 8 Name of�riner — — <br /> WELL OWNER COPY HE-01205-09(Rev.9/05) <br /> ic iao-oozo <br />