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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 7 3 8 6 2 <br /> Henne p i n Minnesota Statutes Chapter 103! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 4 155 n 1-10-02 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 525 Sussex CrI Orono 55356 0 CableeTool ❑ Driven 0 Dug <br /> ❑ Augr Rotary ❑Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. 0 <br /> Spewing property lines, <br /> • i_,,to4s and buildings. DRILLING FLUID WELL HYDAOFRACTURED? 0 YES 10 <br /> N �. ...,, �! .^`4 water <br /> FROM tit() ft. <br /> USE ,/ ❑ Monitoring ❑ Heating/Cooling <br /> I <br /> ---7,---..,.. <br /> ` er Domestic ❑ CommunityPWS <br /> 0 Irrigation ❑ Industry/Commercial <br /> t_ `-� 0 Noncommunity PWS 0 Remedial <br /> w r - ET <br /> .\ 0 Environ.Bore Hole ❑ Dewatering ❑ <br /> r / ,y{ ^ CASING Drive Shoe? 0 Yes ifNoHOLE DIAM. <br /> I - �/ZMile i Y t 1 <br /> ' .ti ! 0 Steel 0 Threaded 0 Welded <br /> S <br /> ) <br /> `? Plastic ❑ — <br /> 1_1 mile—I <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 147 ft. _ _ 2X0.1— lbs./ft. 8 in.to X01. <br /> Tony Eiden Company in.to _ft. _lbs./ft. 6,ii_in.tol__5_5ft. <br /> Property owner's mailing address if different than well location address indicated above. _ in.to ft. _lbs./ft. in.to ft. <br /> 4100 Berkshire Lane SCREE3Ghnson OPEN HOLE <br /> Plymouth, MN 55446 M Dam. <br /> k at1 11.10 ft. <br /> ype <br /> Slot/Gauze .010 _Length 4Z + 4° <br /> Set between 147 ft.and 155 ft. FITTINGS2"x30" w/kp <br /> _ STATIC WATER LEVEL <br /> WELL OWNERS NAME 90 ft./below 0 above land surface Date measured 1-10-02 <br /> PUMPING LEVEL(below land surface) <br /> Well owners mailing address if different than property owner's address indicated above. 143 ft. after 2 hrs.pumping 25 g.p.m. <br /> `�W(E LL HEAD COMPLETION <br /> �E PPitless adapter manufacturer whit lira t e r Model <br /> 0 Casing Protection Lc12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> • <br /> GROUTING INFORMATION <br /> Well grouted? iK Yes 0 No <br /> HARDNESS OF Grout Material 0 Neat cement 0 Bentonite 0 Concrete 4'High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO /� ,/ <br /> from 0 to 30 ft. 2•5 0 yds. IG.bags <br /> clay brown soft 0 18 from 30 tol#-7_ft.natural_b114 ❑ bags <br /> from to ft. D yds. ❑ bags <br /> sand brown soft 18 90 NEARGST�C� SOURCE OF C9NTr AT directio }��-,+� � T r <br /> feetr �^' r <br /> /C-type <br /> Well disinfected upon completion? "(Yes 0 No <br /> clay gray soft 90 140 PUMP <br /> 0 Not installed Date i talled -1—©2 <br /> sand gray soft 140 155 Manufacturer's name <br /> installed <br /> 1.5 230 <br /> Model number HP Volts <br /> Length of drop pipe 126 ft. Capacity g.p.m. <br /> Type: iSubmersible 0 L.S.Turbine ❑ Reciprocating 0 Jet 0 <br /> ABANDONED WELLS ►../ <br /> Does property have any not in use and not sealed well(s)? CI Yes tem, <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes 1No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Don Sto ola Well Drillin co., Inc. 27172 <br /> . ensee Bu ess Name— ic.or Reg.No. <br /> Yom" <br /> 7-16-02 <br /> Authorized Re motive Signature Date <br /> Chuck Moore 1-10-02 <br /> Name of Driller Date <br /> LOCAL COPY 6 7 3 8 6 2 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />