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'��i��� MINNESOTA UNIQUE WELL NO. <br /> WELL LOCATION � MINNESOTA DEPARTMENT OF HEALTH <br /> Counry Name q � ?O�NELL AND BORING RECORD 6 4 2 9 7 4 <br /> H e n n e i n �`�`` ` , � Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Sectiort-N&J� raction WELL DEPTH(completed) Date Work Completed <br /> (h'otto 118 23�� Y 33 ,�, �, �i, 161 n 04 27 OQ <br /> �� House Number.Street Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 2700 Co erview Lane Orono MNSS 23 � Cable Tool ❑ Driven ❑ Dug <br /> PP s s ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map ot well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> N Water <br /> i i � � FROM tt.to ft. <br /> _� _�_ _i_ _i_ <br /> USE ❑ Monitoring ❑ Hea[ing/Cooling <br /> i � � i 1�Domestic ❑ Communit PWS <br /> _i_ _�_ _a_ _i_ O Irrigation y ❑ industry/Commercial <br /> i i i � ❑ Noncommunity PWS ❑ Remedial <br /> w e ❑ Environ.Bore Hole <br /> i i i � ❑ Dewatering ❑ <br /> i i i -r ��'M_a CASING Drive Shoe? ❑ Yes �No HOLE DIAM. <br /> _i i _L_ _i_ I ❑ Steel ❑ Thr/e�a�ded ❑ Welded <br /> ' ' ' ' 1 QS.Plastic (� "�tied <br /> S <br /> f-1 Mile--i <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to 156 tt. Ibs./ft. 1�n4to�S n. <br /> Pillar Aome� ��.lo h. �bs.�nb �4�,.�0161n. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> 125 Lake Street �1. SCREEN OPEN HOLE <br /> �ITB�ZStB� MN 55391 Make ��C-��_ from ft.to ft. <br /> Type ��.' Diam. �e <br /> Slot/Gauze Length J� <br /> Set between� ft.and 1 tt. FITTINGS: dC @T <br /> STATIC�(ATEfi LEVEL / <br /> WELL OWNER'S NAME 13" ft. f�below ❑ above land surface Date measured ���271� <br /> Pillar �O'9ieS PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. fl. after hrs.pumping 25 g.p.m. <br /> WELL HEAD COMPLETION t,p <br /> �Pitless adapter manufacturer �88 Model `� <br /> ❑ Casing Protection '�12 in.above grade <br /> ❑ Ahgrade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Wellgrouted? [,��Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from 6 �to �15 ft. 3 ❑ yds. L�J+bags <br /> from to ft. ❑ yds. ❑ bags <br /> Clay ellow 0 39 from co n. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION OWIl <br /> Ci�.�3t Gray 39 1�5 feet direction type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> Clay & Sand Graq 105 120 PUMP <br /> ❑ Notinstalled Oateinstalled 5/3/00 <br /> Fine Sand Gray 12� 130 nnanufacturer's name Myers <br /> L Model number HP 1 Volts <br /> Gravel � Clay Red 130 IS`� Length of drop pipe I�S ft. Capacity 14 g.p.m. <br /> Sand b Gravel Dark 15�1 161 Type: �'Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)7 ❑ Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes jQ No TNk <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Stevena Drilling � Env. Services 86654 <br /> Licensee Business Name Lic.or Reg.No. <br /> \_ <br /> Authorized Representative Signafure Date <br /> Randy Johneon 04/27/QO <br /> Name ol Driller Date <br /> LOCAL COPY 6 4 2 9 7 4 HE-01205-07(Rev.2/99) <br />