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MINNESOTA UNIQUE WELL <br /> WELL OR 30RING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. <br /> County Name� WELL AND BORING CONSTRUCTION RECORD g�3 4 6� <br /> Minnesota Statutes,Chapter 103I <br /> Township Na e Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> �� " 2-15-17 <br /> GPS LOCATION—decimal degrees(to tour decimal places). DRILLING METHOD <br /> � Latitude Longitude ❑Cable Tool ❑Driven <br /> ❑Auger �otary <br /> House Number,Street Name,City,and ZIP Code of Well Location �Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �No <br /> a Show exact ocation o well/bonng in section r with"X:' Sketch map of well/boring location. ��t��t� From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE �/Domestic ❑Monitoring ❑Heating/Cooling <br /> __j___ __j___ _.!_____;__ ❑Noncommunity PWS ❑Environ.Bore Hole �]Industry/Commercial ` <br /> � ❑Community PWS ❑Irrigation �Remedial <br /> _ _---- -- �YT� �Elevator C�Dewatering ❑ <br /> _ w E t� *� CASING MATERIAL Drive Shoe? ❑Yes �IQo HOLE DIAM. <br /> : � ; ; T r <br /> --,-- --:----�- ---:- ; <br /> [;Steel ❑Threaded ❑Welded <br /> p 1 I � � ne <br /> 'h M' �Plastic ❑ � <br /> -� - � 1 ; <br /> - .- ;--- - � - .- <br /> ; ; ; ; CASING <br /> S Diameter Weight Specifica[ions a /� : <br /> ; �Miie ,r_ . ` � in.To 139 ft. Ibs./ft. v in.To �`'ft. ` <br /> �— --� � ��,� ,-�..�.,.__,_,... -�-�,,�,_ b% 15j'� <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To tt. Ibs./ft. 4 in.To `'lt. <br /> in.To ft. Ibs./ft. in.To ft. <br /> PFop r wne's mai mg dress if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> Make T..l+..e.... From ft. To ft �., <br /> I8225 4Sth Ave N, .�St� �} Type Diam. w <br /> P1S1fMy�th+ t'u'� SJf-F[�V SIoVGauze 4 Length ',y <br /> 1�}����� Set between � � ft.and ft. FITTINGS 'r' <br /> STATIC WATER Measured from <br /> ft.y�elow ❑Above land surface Date measured � <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> RECEIVED LJ� ft after � hrs.pumping � g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> APR 0 4 2017 Pitless/adapter manufacturer �������� Model <br /> ❑Casing protection �(2 in.above grade <br /> Y ❑At-grade ❑Well House [�Hand Pump <br /> C�TY OF ORONO GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material LCX3tv�i1t�From � To 5� ft, 3 ,J Yds. ,�'�8ags <br /> Material(„`(��t f(�s From�O To 13� ft. ❑Yds. ��.Bags <br /> HARDNESS OF Matenal From To ft. ❑Yds. ❑Bags <br /> GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasirgseal From To _Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> �1gy Vr�� ���`� � �� ��>= �7"�� feet �--'�.. direction ��--<... type <br /> .�e C/�Well disinfected upon completion? es ❑No <br /> .�SIKi C1Sy gC�p ��L�R .?C�.� JV PUMP <br /> t� r n n❑Not installed Date installed <br /> �� 1'r� �it �t�� ��v Manufacturer'sname <br /> Madel Number HP 1.5 Volts Ll <br /> Length of drop pipe 1L/� ft. Capacity g.p.m. <br /> Type:� ubmersible ❑LS.Turbine ����Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes o <br /> VARIANCE <br /> ;� Was a variance granted from the MDH for this well? ❑Yes o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is hue to the best of my knowledge. <br /> Use a second sheet,il needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodola Well Dcilling Co�. Inc. 1t9I <br /> Licensee Business Name Lic.or Reg.No. <br /> i ��7 <br /> .--�'" <br /> r <br /> t ' d� epresentative ig ature Certified Rep.No. Date <br /> r <br /> � <br /> 8 2 3 61 Rob scoao�.8 <br /> LOCAL COPY a Name of Driller <br /> ID#52603 <br /> HE01205-15(Rev.8/13) p <br />