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f WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> � County Name WELL AND BORING RECORD 6 2 4 9 0 6 - <br /> He nne�i n Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> fl. <br /> Orono 118 23 35 ,,. ,. �,. � 136• 4-6-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 14$5 LQYl� Lake BiVd. rORO ��SJ3.J ❑ AuberTool ❑ Driven ❑ Dug <br /> g �1 Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> " Bentonite <br /> i � i i FROM ft.to ft. <br /> _i_ _i_ _i_ _i_ <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i �1 Domestic <br /> _i_ _�_ _x_ _i_ ❑ Irrigation ❑ Community PWS ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w E T ❑ Environ.Bore Hole <br /> i i i � ❑ Dewatering ❑ <br /> i i i i I � �� , CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> VzMae <br /> _i � i i_ � � � `� .,�'�L . ❑ Steel ❑ Threaded ❑ Welded <br /> i -i- -i - -i O � �,,, � <br /> v � Plastic ❑ <br /> �-1Mile-� V ' <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to Z 27 n SDR21 Ibs./ft. ?�� 3�}g <br /> Rurt Gr�e�ley ��.�o n. �bs.�n. ' ��.�01�. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. - <br /> SCREEN__y�,Tl$_jS�_ OPEN HOLE <br /> Make from ft.to ft. <br /> Type tainlese .�f'r�@Z Diam. <br /> SIoUGauze Length � <br /> Set between 1� ft.and 1 ft. FITTINGS: '� <br /> STATIC WATER LEVEL y <br /> WELLOWNER'SNAME 70� tt. P?below ❑ abovelandsurtace Datemeasured 4�5�9 <br /> PUMPI�G�EVEL(below land surtace)i �n <br /> Well owner's mailing address if different than property owneYs address indicated above. 1 ft. after hrs.pumping u g.p.m. <br /> WELL HEAD COMPLETION <br /> � Pitlessadaptermanufacturer Whitevater Model __ <br /> ❑ Casing Protection �I 72 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cgtnent RI Bentpnijg ❑ Concrete � High Solids Bentonite <br /> MATERIAL <br /> from � to 3 U R. ❑ yds.�1 bags <br /> Cla�—G1'dvel Y8I1QW S �� 3�j from to n. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAg� OyJN SOURCE OF CONTAMINATiQ,� f'7`a <br /> Gravel—Clay Grey !� 3� �� J� feet ��J�l direction � <br /> �type <br /> Well disinfected upon completion? �Yes ❑ No �""��''�"' <br /> S�IZC� Tt�.Tl M 9� 1�� PUMP <br /> 4-9-99 <br /> ❑ Not installed Date installed <br /> Manufacturer'sname R@y J8Ck2'�. <br /> Model number �15 g � HP � 4 vons 2 3 <br /> Length of drop pipe ft. Capacity �'� g.p.m. <br /> Type: f9 Submeisible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS y <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Q No - <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ 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 /> DON STODOLA WELL DRILLING CQ. , INC. <br /> en e Busines Nam or Reg.No. <br /> 5-�#-99 <br /> Authorized Repres� ive Signature Date <br /> Fred L�iby 5-4-99 <br /> 6 2 4 9 0 6 Name of Dnller Date <br /> LOCAL COPY HE-01205-06(Rev.7/98) <br />