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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINGG UE NO.WELL County Name WELL AND BORING RECORD 770 0 2 5 Minnesota Statutes,Chapter 1031 lipnropin Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 0rcm 117 23 04 NE NE NE 'i 109 ft. 7-22-09 GPS DRILLING METHOD LOCATION: Latitude degrees minutes - seconds ❑Cable Tool ❑Driven ❑Dug Longitude degrees minutes seconds ❑Auger Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ IM. Old Crystal Ann' S, Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �I�lo Show exact location of well/boring in section grid "X."iSketch map of well/boring location. From ft.To ft. � Showing property lines, water N ,.F i �,.� roads,buildings,and direction. USE f-y+f)omestic ❑Monitoring g ❑Heating/Cooling -_______ ______________ F! ❑Noncommunity PWS L Environ.Bore Hole ❑Industry/Commercial �+..._S'1 El Community PWS ❑Irrigation E]Remedial ------ --'------`------`--- \( ❑Elevator "'Dewatering ❑ 4:. TCASING MATERIAL Drive Shoe? ❑Yes [y�ftlo HOLE DIAM. - c. ❑Steel ❑Threaded El Welded --- '/z Mile ' (I,,k __. ..Plastic ❑ s--...., O"' CASING S Diameter Weight Specifications I 1 Mile 1-J 4 in.to 101 ft. 1.9 lbs./ft. a 8_in.to__.. PROPERTY _�OWNER'S INAME/COMPANY NAME m.to ft. lbs./ft. in.to_ . Rehpr,t/Pi izAheth in.to ft. lbs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make Johnson From ft. To ft. same as Alive Type s_ tea _st Diam. 3W Slot/Gauze o.A Length 49 ♦ 41 Set between t{�L t.and tY ft. FITTINGS Y_NX,14R vtkp STATIC WATERJEWL Ul from a!✓ Measured from 45 ft.c4i0Below ❑Above land surface Date measured 7-22-09 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 98 ft.after 1.5 hrs.pumping 30 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION – ' L� ( Fitless/adapter manufacturer I ;"i-4-., 5 t3.-Jw.r.., Model i Casing Protection ),12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) • GROUTING INFORMATION Well grouted [ Yes ❑No Grout materiels ❑Neat cement bentonite ❑Concrete ❑Other From 0 To_50. 4 ❑Yds. wags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_ To 9,!t. natural [fill❑Bags • MATERIAL gravel, pk From 91 To 109 7 ❑Yds. Lidelags NEAREST KNOWN SOURCE OF CONTAMINATION> gs t oil h�� eft 0 riil feat direction _+� "A''''.4Y4,6� Well disinfected upon completion? [. Yes ❑No J — < Jf-..a.-a) cl*y -_yellow* soft 3 15 PUMP } A ❑Not installed Date installed `7! .75 4 C '7 clay gray mat 15 93 Manufacturer's name Model Number HP 1/4<xltfvolts ?.i) sand brown eft 93 109 ✓`1 Length of drop pipe C'_ T r ft. Capacity g.p.m. Type: ubmersible ❑L.S.Turbine El Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑YesNo VARIANCE r Was a variance granted from the MDH for this well? LlYes Wo 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. Tion Stodola Well Drilling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. C res'entativ Signature Certified Rep.No. Date 1 Chuck ?bore LOCAL COPY 77 0 0 25 Name of Driller IC 140-0020 HE-01205-11(Rev.3/07)