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s ` ti � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. � CountyName WELL AND BORING RECORD 6 4 9 2 01 R�III2@ in Minnesota Statutes Chapter f03/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. Orono 117 23 03 ��. �� 1 3 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 6Q/� O ❑ Cable Tool ❑ Driven ❑ Dug C7V �7 Brown Rd �r�n0 5 C7 Auger �Rotary ❑ Jetted Show exact location of well in section grid with" " Sket h map of well location. ❑ 1�howing property lines, A. o,}� roa s a d buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �O — N — � � i � i � � FFOM_ ft.to ft. i -i- -i- -i USE fJ Monitoring ❑ Heating/Cooling i i i i � �� Domestic �j Communi PWS _I_ _J_ _L_ _I_ t„ ❑ Irrigation ry ❑ Industry/Commercial i i i i .� ❑ Noncommunity PWS ❑ Remedial yy E T -�>� � ❑ Environ.Bore Hole i i i i � ❑ Dewatering ❑ i i i -� I � CASWG Drive Shoe? ❑ Yes �lo HOLE DIAM. 'IzMne .-� _i i 1 i � ❑ Steel ❑ Threaded ❑ Welded i- -l- i i �!Plastic ❑ s �-1Mile—� ..�� CASING DIAMETEF WEIGHT PROPERTY OWNER'S NAME _�__.__in.to_��.�ft. � fl��Ibs./tt. __in.to__��tt. T ll! $ ��.co n. _ib5.in. t ��.�o�Z_�n. Property owner's mailing address it different than well location address indicated above. ___in.to__ fl. IbsJft. in.to ft. 7526 Turner �d SCREEN OPENHOLE Inde end�nce M� 55328 "'ake__�1°hns°� ``°m___ n`° n. P 1 Type�_��#�;�.��_ e�t�s�Diam �___ ��` SbUGauze� _._ Length _ � Set between _� _ ft.and R. FITTI GS: STATIC WATER LEVEL WELL OWNER'S NAME __5_5—_ R. C�below ❑ above land surface Date measured ��77.+11 PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. 1_1_�___ ft. after __,___,�_ _hrs.pumping �_._g.p.m. WELL HEAD COMPLETION f�Pitless adapter manufacturer ..L.1 •....��Model • f� Casing Protection__. __._ �12 in.above grade �� ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement f7 Bentonite I� Concrete �High Solids Bentonite MATERIAL from�__to__ 3i�.ft. ___^y_�5❑ yds.�'bags from_��--to�_'}�ft. �a��a_� f��d�1 bags i from to ft. ❑ yds. ❑ bags � NEAREST KNOWN SOURCE OF CONTAMINATION __ 1`in_feet _ _�. direction`+��y _Qn�2.pt�pe ) .��.�.. Well disinfected upon completion? ,jS�Yes f 1 No PUMP ❑ Not installed Date installed 6'1��Q Manutacturer's name - Model number_ HP �_ . Volts��8_ _ 7 Length of drop pipe___�_ ft. Capaciry _ g.p.m. Type: �Submersible ❑ L.S.Turbine f7 Reciprocating ❑ Jet ❑ _ f ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �No VARIANCE Was a variance granted from the MDH for ihis well? ❑ Yes �No TN#_ : i - WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best ot my knowledge. i REMARKS,ELEVATION,SOUf10E OF DATA,etc. Licensee u*smes' s Nam��'`��fl�or'R�g.7J�� , �:.=f�,.:_....� ��-��-d.�-*�-`�10-4-00 ; - - --- - _ —_ ---- -- � � Authorized Represenlative Signature Date i Chuck Maore 5-22-00 r . _ _------ - -— - 6 4 9 2 01 Name o�Driller Date LOCAL COPY HE-01205-07(Rev.2/99)