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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 g� 5 3 9 <br /> Hennepi n Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Com eted <br /> Orono 118 23 31 NW SE SE " <br /> ,,, ,, , 15Q 3/4/04 <br /> GPS DRILLING METHOD <br /> Latitude degrees minutes seconds <br /> LOCATION: ,�Cable Tool ��Driven � ]Dug <br /> Longitude degrees minutes seconds �.-- —� <br /> _i Auger �Rotery �Jetted <br /> House Number,Street Name,City,and Zip Code of Well�ocation or Fire Number i` <br /> 525 �CC111�.� Rd• w2l zata, �n 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �No <br /> Shop exact location of well in section grid with"X". Sketch map of well bcation. Baro i d qu i k gel FROM ft.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE , I��Monitoring [�Heating/Cooling <br /> -� ; � ; .--� L i Domestic ❑Environ.Bore Hole �Industry/Commercial . <br /> --'--- '-----� _ 1 _. . <br /> " �i Noncommunity PWS ��Irrigation J�Remedial <br /> �J Community PWS i_]Dewatering � <br /> : 1 � ,,��....._, — <br /> '--" ""' - ---� ` �' CASWG� Drve Shoe? ❑Ye f'�� HOLE DIAM. <br /> w E 1.� . .. -, ..i s No : <br /> ' ' T . � .. Id d <br /> � --> Steel hreaded e e <br /> -- -- — -- - - �J �J T ❑W <br /> - � - - - � � � .. . � Plastic —, <br /> . 'hI Mile .... .. � fr. .,.� � L' ': <br /> �. '--' """ ' f- 1 . --�� �^""' CASING DIAMETER WEIGHT � <br /> � S 4 �,,.to 14 0 n 1.9ibsJft. �� m.to 3� rc. ' <br /> �-1 Mile� / <br /> f, . .t� /}�,'(� - ..__.._. in.to tt. IbsJft. 6� in.t��Q ft. <br /> ..t f <br /> � PROPERTY OWNER'S NAME/COMPANY NAME .. in.to fl. Ibs./ft. in.to_ ft. <br /> Chris Stie hens Cdnst.• SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make___Cres1 ne FROM tt. TO ft. <br /> Type�la$�iC rN <br /> 37?5 CO. Rd. 92 SIoUGauze �� Length ��_ea � <br /> Mez le Plafn, Mn 55359 Setbetween 14f1 ft.and ��}A ft. FITTINGS <br /> P STATIC WATER LEVEL <br /> __v�_ft.i�below � ,I above land surtace Date measured___�.��_ <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> 5 ft.after__ �__hrs.pumping � g p m. <br /> WELL HEAD COMPLETION <br /> Well owner's maiting address if different than property owners address indicated above. ��pitless adapter manufacturer��'1��e'� -Pt' _ Model�.u__l�___ <br /> Casing Protection [�12 in.above grade <br /> [i Ahgrade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted ��Yes [j No <br /> Grout material i�;Neat cement ❑Bentonite ❑Concrete�High Solids Ben[onite . <br /> from 30 to � tt. � ❑yds. QQ bags, <br /> " from__to tt. �j Yds ,_�bags I <br /> GEOLOGICAL MATERIALS COLOA HARDNESS OF FROM TO from_, to ft ��,Yda �_,oags� , <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION �I <br /> yelTar� elay br�wn soft 0 35 ��_ ree� _north direction _$ePt�C tyPe <br /> Well disinfected upon completion �',Yes �,No tank <br /> blU$ C.l.a� C�Xa� LROfL 3S $� PUMP <br /> I Not installed Date installed <br /> Cl�Y � eand gray 80g1'i 85 13 'rJ IManufacturer'sname Aarmotor <br /> .a e Modelnumber HP 1 _1/�o�lfts "O <br /> � garlu gray $�f t'i i 3.l 150 Length of drop pipe 1 ft Capacity `O g.p.m. <br /> i — <br /> . Type�Submersible [I LS.Turbine 1-I Reciprocating '�Jet [; <br />�� ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) ��Yes I No <br /> VARIANCE <br /> Was a variance granted from the MDH for this wel�? ,___�Yes I No TN# - <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The intormation contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needad A <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Le11t.YLII@r we�.l Inc. 1 V 1 ZS <br /> Licensee Business Name _ /'`� Lic.or Reg.No. <br /> ,'� � � <br /> �, -� ' � ti/�y <br /> J <br /> AJthoriied Representative Signature � Date � <br /> Maurice L. Leuthner 5/21/04 <br /> �9 2 5 3 9 Name ol Driller Date _ . <br /> LOCALCOPY Ne-o�zos-oeiae�.sioz� , <br />