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MINNESOTA UNIQUE WELL <br /> WELUBORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD <br /> Hennepin Minnesota Statutes,Chapter 1031 742738= <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono lion23W 33 81,/ 154 tt. July 26, 2006 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude_ degrees minutes—_ seconds <br /> El Cable Tool Driven ❑Dug <br /> Longitude degrees minutes seconds_ ❑Auger I*otary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location,., or Fire Number 11t�s <br /> 160 Old j tal � ong Rd X. � La DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well location. 111Rts <br /> From ft.To <br /> Showing property lines, N. <br /> N roads,buildings, USE Domestic Monitoring ❑Heating/Cooling <br /> n on. ❑Noncommunity PWS Environ.Bore Hole ElIndustry/Commercial <br /> - --- - ------`-----`-- ❑Community PWS -.Irrigation ❑Remedial <br /> ❑Elevator ❑Dewatering ❑ <br /> -"�-"- --i--"----"---r-- CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. <br /> W E T ElSteel ❑Thread d E)Welded <br /> V lastic <br /> --- ------ <br /> /z Mile CASING <br /> :--- -:-- ---: 1 <br /> I Diameter Weight Specifications <br /> S81 <br /> i 1 Mile 4 in.to 159 ft. lbs./ft. in.to y4" ft. <br /> in.to ft. lbs./ft. in,to i��ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> Leann COO SCREEN OPEN HOLE <br /> Property owner's mailing ft <br /> g adddress if different than well location address indicated above. Make Ja C <br /> CrQ From ft.To . <br /> 10 Old "tal UyRd N Type Dia.. <br /> Long Lake, MN 553% Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS packer <br /> STAT W\fTER LEVEL 7-26-06 <br /> 141 ft.kelow ❑Above land surface Date measured - <br /> WELUBORING OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> Leann Goe ft.after hrs.pumping 1 g.p.m. <br /> " <br /> Well boring owner's mailing address if different than property owner's address indicated above. W LL HEAD COMPLETION 4J%Pitless Adapter Manufacturer Model <br /> I I Casing Protection 12 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? '(Yes ❑No <br /> Grout materials 11 Neat ceme.pt_[�entonit 16Concrete ElOth�r <br /> From (� To ft. ❑Yds. Bags <br /> From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To_. _ ft. ❑Yds. Bags <br /> MATERIAL — <br /> clay yellow {? 45 NEAREST KNOWN SOURCE OF CONTAMINATION Over 50' from sewer <br /> feet direction ___type <br /> Well disinfected upon completion? ' Yes 11 No <br /> Band gravel alXCd 45 78 PUMP <br /> ❑Not installed Date installed <br /> clay gray 70 145 <br /> Manufacturer's name <br /> IM Sand gray 145 164 Model Number a HP Volts __.. <br /> Length of drop pipe ft. Capacity / g.p.m. <br /> Type: ubmersible ❑L.S.Turbine ❑Reciprocating -i-1 Jet -i <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes KNo <br /> VARIANCE ,[ <br /> Was a variance granted from the MDH for this well? ❑Yes ANo 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,it needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. SUVOW Drillias 6 Envireumw l Svc 2255 <br /> Licen usiness Na' Lic.or Reg.No. <br /> h <br /> Authorized Representative Signature Date <br /> handy Johnson <br /> LOCAL COPY � 742738 �Name of Driller <br /> HE-01205-09(Rev.9/05) <br /> IC 140-0020 <br />