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� M/NNESOTA UNIQUE WELL �WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. 'County Name WELL AND BORING CONSTRUCTION RECORD g 1 g 0 2 4 Minnesota Statutes,Chapter 10.3I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED , ,, IS1 h 3-25-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven [I,Auger �Rotary � House Number,Sireet Name,City,and ZIP Code of Well Location ❑Other � 3�75 Facwiew Lane, OCQL�Q 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �,��r From ft.To ft. � Showing property lines, ro ds,buildings,and direction. USE N e"' � , �Domestic ❑Monitoring ❑Heating/Cooling , , , , � �� s�'.J,• "" Environ.Bore Hole Industr/Commercial __;__ �___ _ �_ __,_ ❑Noncommunity PWS [� ❑ Y �� ❑Community PWS ❑Irrigation ❑Remedial �' ' ' ' ___;_ � �Elevator ❑Dewatering ❑ �; w � ; ; ; e CASWG MATERIAL Drive Shoe? ❑Yes �'No HOLE DIAM. --�--- --�--—�-----*-- /M�` �J Steel ❑Threaded ❑Welded s ❑ '� lastic 1 --�----�- --�-- --� � � -- „�,�---+...�,� CASING ' ' S ' � � ) Diameter Weight Specifications �—�Mile—� � in.To 1�ft. Ibs./ft. in.To_�_ft. PROPERTY OWNER'S NAMEiCOMPANY NAME in.To ft. Ibs./ft. � in.Tol JL R. ; asbe Stofferahn in.To ft. Ibs./ft. in.To n. OPEN HOLE ; Property owner's mailing address if different than well location address indicated above. SCREEN � Make �� From ft. To tt. Type 4td�T1�A+�$ $t�� Diam. SIoVGauze �� Length � ��t Set between ft.and ft. FITTING STATIC WATER LEVEL Measured from :i � ft.�Below ❑Above land surface Date measured " � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 1 I3� ft.after 2 hrs.pumping 50 g.p.m. ' Well/boring owner's mailing address if diflerent than propert er' d e r ted above. WELLHEAD COMPLETION .� � �Pitless/adapter manufacturer �t��$t�r Model � ❑Casing protection „[5�12 in.above grade CITY OF ORONO �At-grade ❑Well House [,i Hand Pump - GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material�@(I�fn't�tP_ From�_To��_ft. __�_ ❑Yds. �'Bags Matenal ttll Cfl1Si� �r�r��To�f�_ft. �Yds. �Bags HARDNESS OF Matenal From To ft. ❑Yds. []Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION t��$�j l black 8�f t � 2 �>y} feet -..:: direction �_type Well disinfected upon completion? es [�No � �SyI�',L'fiV'E.'1 �.?CdWII I�IEq Z �I PUMP ; ,t 1 t/� []Not installed Date installed .T![J�� �ay �ra�7 �1�) �i 11J7 Manufacturer's name �j�'��r y _ - [DU�gravel �}J.�i 171G�11i� if1'7 �� Model Number HP �1�� Volts �� tJ! Length of drop pipe � ft. Capacity g.p.m Type: Submersible ❑L.S.Turbine ❑Reciprocating �Jet ❑ 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 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodo2a 4�Te11 Ikillin�; Co,.Inc. 1691 Licensee Business Name Lic.or Reg.No. , � ___� :�,-, 4 5-16 .�,'l f,•�� f, .. _ !.� "� ,. q. Representaiive Sig�ature Cerlified Rep.No. Date LOCAL COPY g 18 O 2 4 Name of Driller ��v .7t�OI� . ID#52603 HE-01205-15(Rev.8/13)