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�(z WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. Ccunty Name WELL AND BORING RECORD 6 9 2 � 3 3 ge��p� Minnesota Statutes Chapier 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono I181� 23ii 31 ,� ,,. ,� 182 n 7-30-d3 GPS DRILLING METHOD Latitude degrees minutes seconds _ LOCATION: �- j_�Cable Tool (J Driven _J Dug Longitude degrees minutes seconds _J Auger �$otary ;_I Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �j 4385 Chippewa Ln, OLOI20 DRILLING FLUID WELL HYDROFRACTURED? j]Yes " No Shop exact location of well in section grid with"X". Sketch map of well location. �Iltonite FROM tt.TO tt. Showing property lines, N , roads and buildings USE f]Monitoring r��Heating/Cooling .: `-:-,_"""""'. �/� ' - ; , , � _.,__ ��^^^'� ,aiy7 r]Environ.Bore Hole [�Industry/Commercial L omestic _ ` ^r� �� I]Noncommunity PWS [��Irrigation �r J Remedial � �^4M""""`�� ❑Community PWS ❑Dewatering ❑__ - --'- i-- ---`---- ` . `, W � ; E� % t f; Drive Shoe? j=;Yes �No O�E DIAM. H �; _;_ �___ _.�___ , , /t't'` � ��._'',Steel �.Threaded• �,_I Welded �� ? CASIN . , , '/z Mile � : �_ � 18StiC ��' — - ---- - I va�i . . [� t',. � 1 �j CASING DIAMETER WEIGHT � � S � � � L O�f �`� ~ in.to a`� ft. tbsJft. � • in.to y�ft. f--1 Mile—� { .'+i.fYl��i � V � lOL in.to ft. Ibs./ft. � in.to_ ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. .1. �81C Fritzler � Despl L. Peteraoa SCREEN OPEN HOLE Property owner's mailing address if differert than well location address indicated above. Make J8�C0 FROM fL TO ft. 4385 Chippewa Ln TYPe --� De� --� — Maple Plain, � 55359 SIoUGauze gth _ Set between ft.and ft. FITTINGS_��er STATIC WATER LEVEL 183 tt. below ,l'above land surface Date measured__7-30-03 PUMPING LEVEL(below land surface) WELL OWNER'S NAME/COMPANY NAME J, I�arc Pritzler b Desyl L� PetersoA h.aher n�s.PUmP��9— SQ'f' g.p.m. LL HEAD COMPLETION p �� Well owner's mailing address if different than property owners address indicated above. i�itless adapter manufacturer_ �a8a Model � __ �� �Casing Protection � �_�12 in.above grade �'��At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATIO� Well grouted Yes 'L.I No Grout material '�'',Neat cement�j Bentonite i�Concrete ��High Solids Bentonite from 6 to �� n. 3 �J yds ['bags from to _ft. ❑yds [i bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. [J yds. ��.bags MATERIAL NEAREST KNO�WN SOURCE OF CONTAMINATION _ Clay Yello�r 0 30 _ er 54 aaaq _ Q� feet direction type Weil disinfected upon completion ��Yes [�,No Ci1831 Gray 'jfl 9Q PUMP �j ��Not installed Date installed ` _�� �i`Y8'Ve�. M�7CE� QQ i�rj IManufacturer's name '!�{�� --' Model number HP ` Volts Gravel & Clay �@d 135 170 Length of drop pipe /i;.*^•�,e _ft. Capaciry ( � g.p.m. Type: � �Submersible ❑LS.Turbine ❑Reciprocating ��Jet ❑ Gr84E�. M�Xed 170 1�2 ABANDO ED WELLS Does property have any not in use and not sealed well(s) ❑Yes � No � VARIANCE Was a variance granted from the MDH for this well? '�Yes �,-� No TN# WELL CONTRACTOR CERTIFICATION 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 of my knowledge. Use a second sheet,il needed REMARKS,ELEVATION,SOURCE OF DATA,eta sti@V@fl8 Drilling � Enviro�ental Svc 86654 ,. —._. _—_ . __— —�--- ---- ---- � - Licensee Business Name Lic.or Reg.No. - ��\ � \` x ��f V J 1 � � 7 Authorized Representative Signature Date aanay Joh�Bo� _ ::��:l �, � _ - --- -- --- ---- - LOCAL COPY 6 9 2 8 3 3 Name of Driller oate HE-01205-08(Rav.5/02) IC 140-0020