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r � . WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o��tY Name WELL AND BORING RECORD 6 6 H O 3 O Minnesofa Statutes Chapter103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono 317 23 8 ,. ,. ,. 125 " 8-29—01 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD 3510 N Shore Dr, �r�A�} 55391 ❑ CableTool f7 Driven ❑ Dug ` �"' Auger �Rotary ❑ Jetted ; Show exact location of well in section grid with"X". Sketch map of well location. :_ . � _ ___ .__.____ __-- — Showing property lines, � `-"""—`-- roads and buildings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES " Water i i � i FROM ft.to_ ft. -i -i- -�- -i- -- USE Cl Monitoring ❑ Heating/Cooling i � i i �Domestic ❑ Communiry PWS ❑ Indust /Commercial � � � i � � Irrigation ❑ Noncommunity PWS G Remed al w I I I I e� �`�.��,1\ . ❑ Emiron.Bore Hole ❑ Dewatering �_:, _ i _, -T r '/zMie _.. . CASING DriveShoe? ❑ Yes No HOLEDIAM. i _i_ _i_ _i_ � ❑ Steel. ❑ Threaded ❑ Welded '� � � � 1 �J . �.. .... �� Plastic ❑ S .t,'.._ .._r_. � _ /� . �-1 Mile--{ CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � in.to !j'8 ft. 2'01 Ibs./ft. 8 in.to '��ft Raleidoscope D�sfgn LLP �� o _.__�. __ __�bs.�tt. S<;�.�ol�,,. Property owner's mailing address it different than well location address indicated above. __—_-- ___in.to _____ft. Ibs./ft. in.to____ft. 26890 Noble Ad SCREEN_._�y�sO�_ OPEN HOLE Shorevaod, MN 5533T `'�''�` _ Make from ft.to_ R. Type� _�� _..____Diam. ' � SIoVGauze_._ •il�� Length , �� Set between _��____ft.and___�.��__ft. FITTINGS��__ STATIC WATER LEVEL WELL OWNER'S NAME _�__________ft. �below ❑ above land surtace Date measured�—?_9 Q� PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. __ _1_1_�_ tt. after 1 hrs.pumping�.�__ g.p.m. WELL NEAD COMPLETION ,,�y j �PiNess adapter manufacturer �111 L ep$t e��vl,ordel ❑ Casing Protec�ion_ _ I]y 12 in.above grade C At-grade(Environmental Wells and Borings ONLY) � GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete ['�I+�High Solids Bentonite MATERIAL � �Q __�j� Y � 9 from to ft. ds. ba s tp +� trom_�__.._.to._��fl. �8,�_$,�_$� C��d��1 bags t0�1g�1� b�BC� ��it Q J trom _ _ to_ fl. ❑ yds. ❑ bags NEA/R��S/T�)$NC,WN SOURCE OF CONTAMINATION �� +C (�"1$� gr8'�/ �(�f t ,7 �Q ___1S,L ._ feet _��.� �direction � t _type Well disinfected upon completion? C�'es ❑ No sand/�ravel gray soft 90 12b PUMP CJ Not installed Date installed Q�[7�n1� Manufacturer's name [1et�Q�� _ Modelnumber __.______.____ _._ HP�9 Volts L�� Length of drop pipe.__ ��._..__ __ ft. Capacity g.p.m. Type: ubmersible G LS.Turbine ❑ Reciproca6ng ❑ Jet ❑ ABANDONED WELLS � Does property have any not in use and not sealed well(s)? ❑ Yes �No VARIANCE Was a variance granted from the MDH for this well7 ❑ Yes CJ�No TN# _ ! WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minneso[a Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to Ihe best of my knowledge. �_�flri 7 t inrr (`.n_ T�n�T9 I�'� Lice ee Business Name � ic.or eg. o. .f,:,� / � ��=� `�` ` �--�" 9-2A�n� Authorized Representative Signature Date Chuck Moote 8-29—OI Name of Driller Date LOCAL COPY 6 6 8 0 3 0 HE-01205-07(Rev.2/99) IC#140-0020