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MINNESOTA UNIQUE WELL WELL 9I4430,,FtING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD • Minnesota Statutes,Chapter 1031 , 8 2 6 6 5 9 -Towns r Township No. Range No. Section No. Fraction(sm.—.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED . Orono 117 23 — 07 EX NE/ DRILLING METHOD n 10-12~47 GPS LOCATION—decimal degrees(to four decimal places). Latitude Longitude ❑Cable Tool n Driven ❑Dual Rotary 00 ❑Auger Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑.dN1er Pb t + � 55364DRILLING FLUID WELL HYDROFRACTURED? ❑Yes yNo Show exact location of well/boring in section grid with"X" Sketch map of wet/boring location. blt�te From ft.To ft. ' ' Showirspro lines, N roads,building3°a irection: USE /Domestic ❑Monitoring ❑Heating/Cooling IM ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commerdal ❑Community PWS ❑Irrigation ❑Remedial -- ------ - ❑Elevator ❑Dewatering ❑ w E CASING MATERIAL Drive Shoe? yrYes ❑No HOLE DIAM. Steel XThreaded ❑"Welded %Mile ❑Plastic ❑ .. 1- CASING g I Diameter * Weight Specifications 8 1 Mile 4 in.To 310 ft.- lbs./ft. in.To 50 ft. PROPERTY OWNER'S NAME/COMPAN ME in.To ft. lbs./ft. 1/4 n.To � ft. R ger in.To ft. lbs./ft. 37/8n.To ft345 . Property owner'smailing aIgi tigisits if different fh�aaalt location address indicated above. SCREEN OPEN HOLE Make From ft. Toy ft. Type Diam. Slot/Gauze Length ;- RECEIVED i Set between ft.and ft. FITTINGS r STATIC WATER LEVEL 74 IX Below ❑Above land surface >t DEC 0 LU I Measured from Date measured 1042��r Dry hole ❑Yes No i WELL OWNER'S NAME/COMPANY NAME 1 PUMPING LEVEL(below land surface) 2 y� r 230 ft.after hrs.pumping 100 g.p.m. t Well/boring owner's mailing address if different than pro�o n dlyrdskCINitdd above. W LLHEAD COMPLETION Pitless/adapter manufactur t tSr Model ❑Casing protection le12 in.above grade (. ❑At-grade ❑Well House ❑Hand Pump r GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,3concrete,cuttings,or other) Material bentonite From 0 ToNY ft. ❑Yds. Bags eS Material r ,tlfigi From__ To _ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds ❑Bags ` 'GEOLOGICAL MATERIALS COLOR FROM 'TO Dr ven casing seal From To Bagsbag= MATERIAL One 94 lbs.cement or 50 lbs.bentonite P NEAREST KNOWN SOURCE OF CONTAMINATION b id 0 /v�d W l'a"'"time Well is feet direction from j `'l' ' ' Well disinfected upon completion? A Yes E No gray imam 45 74 PUMP � 74 210 1046-47 r ❑.Not installed Date installed gray soft 210 n3 Schaefer soft 243 Manufacturer's name erit+ Model Number 1 HP _Volts 210 y lledilini 243 289 i. serdiebeyLength of drop pipe 105trwray medium 289 3436 ft. Capacity g.p.m a( e white/pink hawk 306 345 Type:$Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 7 ABANDONED WELLS '. Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE j Was a variance granted. from the MDH for this well? ❑Yes No TN# WELL 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 Sto+f- n Drilling Cot. I . 1691 Licensee Business Name Lic.or Reg.No. if Amer' d- � ' 11 17417 if R presentativ6`Signature Certified Rep.No. Date }' LOCAL COPY 8 2 6 6 5 9 Name of Driller ID#52603 HE-01205-16(Rev.5/16)