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_ � _ ^ MINNESOTA UNIQUE W�LL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTFi AND BORING NO. ' co��,y Name "} WELL AND BORING CONSTRUCTION RECORD g 18 0 3 6 �.��n Minnesota Statutes,Chapter 10.3I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED `,e Orono 11�3 23 25 N,� S"GJ� SE ,� 2^� K 7-1-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven ❑Auger �Rotary Hg�use NurPbser,�re�et Nrar e, 'ty,�r�ZIP Code of Well Location '�Other Tettcli �. DRILLING FLUID WELL HYDROFRACTURED? j I Yes No S ow exac o tion o we/ ring in section grid with"X° Sketch map of welUborin location. �ter From ft.To ft. Showing pro rty lines, � N roads,buildings,an direction. USE �Domestic ❑Monitoring [I Heating/Cooling F •. __j____j___ _.�____;_ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �'. � ❑Community PWS �Irrigation �J Remedial ❑Elevator ❑Dewatering ❑ w E �� CASING MATERIAL Drive Shoe? Yes ❑No HOLE DIAM. ��- ; � � � � + ""'""' --�--- ---�-" ---'-- T hreaded elded F � �,Steel �T ❑W ',�� ; , '/Miie �°r��l� ,r��"�� Damleter��Plastic ❑ ; S 1 Weight Specifications i 1 Mile� � � in.To ��ft. Ibs./ft. �in.T�ft. ,� i Z PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �.Tq�ft. Caldwell �3Anker T3uc-net-G�eocge Stickney :�i/t3 ca� in.To ft. Ibs./ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. 2� Z$g ZQ�, �',, �$�C@ St Make From ft. To ft. t��3 Z�3t8 f''�i1 55391 Type Diam. Y 7 SIoUGauze Lengfh Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from c F . ��___ft. Below �Above land surface Date measured ��1""IC7 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) RECEIVE� 23� ft.after � hrs.pumping �O g p m. Wetl/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION APR 0 4 �(� � !�Pitless/adapter manutacturer Model �"�•' �_'.Casing protection �12 in.abovye grade [j At-grade ❑Well House ❑Hand Pump �.nita aS,�l .y��F��ONo GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) MaterialbenCOniLe From � To��Q ft. � ❑Yds. �Bags Materiall��.��Z �� 0 To L�"'ft. �Yda [J Bags HARDNESS OF Material From To ft. ❑Yds. �J Bags � GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags r t NEAREST KNOWN SOURCE OF CONTAMINATION �I�y �� '� � 2j' �� feet �" direction � � � t—� type $� C $}� rQ� � Well disinfected upon completion? �i Yes [,'No 4 san�ly c2ay �ray mec�iwn 36 98 PUMP � a! �n � � � � sa [;Not installed Date installed ��21�16 �� �CQWIl � Manufacturer's name c ay �;ray um A sandy 'l.'�laj� �r$� SQit i�5 233 ModelNumber L HP G Volts 230 �n y � 8y �r8y $Q Length of drop pipe �v� fL Capacity g.p.m. (��.Y'ty S$P��j[a�tQ j��{ �t�,�i'�! 253 2`J! Type: Submersible ❑L.S.Turbine ; ]Reciprocating ❑Jet ❑ ABANDONED WELLS 41if.'8CCR1L �2 OW SL ...• b�� Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE . Was a variance granted from the MDH for this well? ❑Yes No TN# WE�L 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 Stocio2a Well Drilli Ca . Inc. 1691 Licensee Business N me Lic.or Reg.No. '� 12-21-15 rtifi epresentative ignature Certified Rep.No. Date ` Q Iy�1� ^{ Rob StaiOla " . L�CiAL Ci�PY . - ... (J 1 V�O J� � Name of Driller . . .. ID#52603 HE-01205-15(Rev.8/13)