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MINNESOTA UNIQUE WELL <br /> WELL OR`BORING LOCATION , MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name - WELL AND BORING CONSTRUCTION RECORD 826639 <br /> ...,..r�i.. Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono .117 23 07 NW St SE ,/. 96 n. 8. 30-17 <br /> GPS LOCATION=decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool n_Dnven <br /> ❑Auger Rotary <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 4005 North Shore Dr, orono 55364 DRILLING FLUID WELL HYDROFRACTURED? LI Yes I'f�No <br /> Show exact location of well/boring in section grid with"X:' Sketch map of well/bori location. bentonite From ft.To J ft. <br /> Showing prorty1ines; <br /> N loads,buildings,an direction. USE Domestic ❑Monitoring ❑Heating/Cooling <br /> --- , ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> --- •--'---' --- ❑Elevator ❑Dewatering ❑ <br /> w E CASING MATERIAL Drive Shoe? ❑Yes Slo HOLE DIAM. <br /> t T ❑Steel ❑Threaded ❑Welded <br /> mite Plastic ❑ <br /> CASING <br /> T s Diameter . Weight Specifications <br /> I---tMile 4 in.To ft. lbs./ft. 8 in.To _ft. <br /> PROPERTY OWNER'S NAME//CO PANY NAME in.To ft. lbs./ft. in.T _k. <br /> Jim & Vicki Splinter in.To ft. lbs./ft. in.To ft. <br /> SCREEN OPEN HOLE <br /> Properlown�e'smatilian�gaaddreess�iffdli(f+efreM than well location address indicated above. Make athroon <br /> �a�� 'yam <br /> Austin, Mg 55912 Tyle standees steel From <br /> ft. To ft. <br /> SIoUGauze 86.010 Length 41 + 41 <br /> RECEIVED Set between ft.and 96 ft. FITTINGsnrlf leador <br /> STATIC WATER LEVEL <br /> Measured from <br /> MAR0 2 2Q18 40 fteBelow ❑Above land surface Date measured 8.1047 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> an ft.after <br /> 2 hrs.pumping 40 q.p.m.WelUbonngowner's mailing address if different thanprfitjI. /n a p`nAr above. WELLHEAD <br /> COMPLETION � - <br /> XPitless/adapter manufacturer 7 +tf ter Model <br /> ❑Casing protection Ar12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material b! 'ltOflite From 0 To ft. 3 0 Yds. 'Bags <br /> Material' ti� From 7 To ft. <br /> yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL Driven seal From To Bags <br /> C lay brown medium 0 * NEAREST KNOWN SOURCE OF CONTAMINATION <br /> .5 feet *...++. `direction f` 'ZI...2.8.-k—t-lype- <br /> sandyclay *9 37 Well disinfected upon completion? Yes ❑No <br /> �rssJ i9 PUMP <br /> - sand mix <br /> soft 37 96 ❑Not installed Date installed 811481116 �i/ <br /> �.a.:;18 <br /> Manufacturer's name Schaefer <br /> Model Number Hf Of Volts <br /> Length of drop pipe ft Capacity g.p.m, <br /> Type Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yesf No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes le No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Don St la * Drilling Cosi Inc. 1691 <br /> Licensee Business Name i Lic.or Reg.No. <br /> .e <br /> z 1-•15-18 <br /> `ifi- • .resents iv=, ,,, -rre Certified Rep.No. Date <br /> 826639, <br /> ^{ Q Rob Shia <br /> LOCAL COPY V 2 6 6 3 9 Name of Driller <br /> ID#52603 <br /> HE-01205-15(Rev.8/13) <br />