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� � - <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. <br /> ' CounryName WELL AND BORING RECORD 6 2 4 916 <br /> F Hennepf n Minnesota Statutes Chapter 103! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Orono 118 23 36 ��. ,. ��. 148' 2-16-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool Driven ❑ Dug <br /> �75 Aiol th Ferndale Rd. Ozotlo Mn.55392 ❑ Auger � Rotary ❑ �etted <br /> - Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ <br /> Showing property lines, <br /> N � t,��S and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> '��`{� Bentonite <br /> , , , , FROM n.co n. <br /> -,- -;- -,-- -,- ., <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i [�CDomestic <br /> _i_ _�_ _�_ _i_ ❑ Community PWS ❑ Induslry/Commercial <br /> i � i i ❑ Irrigation ❑ Noncommunit PWS <br /> w E T ❑ Environ.Bore Hole Y ❑ Remedial <br /> i i � i ❑ Dewatering ❑ <br /> -r -�- -r- -r <br /> i � i i �ZIMie CASWG Drive Shoe? ❑ Yes C�No HOLE DIAM. <br /> _i_ _i_ _i_ _i ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> � S 1 � ,/'),Q�� ;�] Plastic ❑ <br /> �-1Mile-� ��� �J' <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME '4 in.to 192 ft. +�D�'2� Ibs./ft. ? 7�� 3Q <br /> Jim � '�Ieagt�n Dayton ��.�o n. ibs.ih. 6�,�.t�,98n. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make from ft.to ft. � <br /> Type Stainiess St�Cl. Diam. <br /> SbUGauze 'Ap Length_�� <br /> Set between ft.andy�ft. FITTINGS:3� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME �00 ft.�l below ❑ above land surface Date measured 2�1��9 <br /> PUMPING LEVEL(below land surface) . <br /> Well owner's mailing address if different than property owner's address indicated above. 1 y 0 ft. after 3 hrs.pumping �� g.p.m. <br /> WELL HEAD COMPLETION <br /> �Pitless adapter manufacturer Model <br /> ❑ Casing Protection C�12 in.above grade <br /> ❑ At-grade(Envirbnmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? g Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement C�Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from�to�Q_ft. �� O yds. �C bags <br /> from to ft. ❑ yds. ❑ bags <br /> Sandy Clay Brown S 0' 20• from io n. ❑ yds. ❑ bags <br /> NEAR NSOURCEOFCONT ATpI ,N J g ) f�, <br /> Clay {jj'@�f S 20� �r'j� � feet � [/L.�' direction �+ type <br /> Well disinfected upon completion? es ❑ No <br /> Ciay-Grav�Y Bro�rn � 4�� �y�� PUMP 8l��w9� <br /> ❑ Not installed Date insta ed <br /> Sand �`il'tl'V��. T21i1 S �7cJ� 48r� Manufacturer'sname <br /> Re� ac e <br /> Model number HP Volts <br /> length of drop pipe 1�6 ft. Capaciry 1 8 g.p.m. <br /> Type:�E7 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS X <br /> Does property have any not in use and not sealed well(s)? ❑ Yes -❑ No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 1J Yes ❑ No TN# <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 /> DOId STODOLA WBLL DRILI.ING C0. , INC. <br /> Licensee Busin s Name Lic.or Reg.No. <br /> � 9-10-99 <br /> � ,_.-` <br /> Authorized entative Signature Date <br /> Fred Lefby 2-15-99 <br /> Name ol Driller Date <br /> LOCAL COPY 6 2 4 916 HE-01205-06(Rev.7/98) <br />