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, �z MINNESOTA UNIQUE WELL �WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. : �o��tY Na�,e WELL AND BORING CONSTRUCTION RECORD 81 O 8 9 O Minnesota Statutes,Chapter 103I ; Township Name Township No. Range No. Section No. Fraction WEWBORING DEPTH(comp�eted) DATE WORK COMPLETED A '� 11� �� QV i9aCi tri7i JCi'/ �.�� n� C�.. .� GPS LOCATION—decimal degrees(to four decimal places�. DRILLING METHOD Latitude Longitude ❑Cable Tool []Driven ❑Auger -�I Rotary House Number,Street Name.CI?y.�nd ZIP Code of Well Location �.Other '�� 559 PackI.�ane �' S5356 DPoLLWG FLUID WELL HYDROFRACTURED? JI Yes �lr�No ��.� Show exact location of well/borina i�.��.��.:-'�on grid with"X:' Sketch map of well/boring location. �r�ter From ft.To tt. �, � Showing property lines, "- roads,buildings,and direction. USE . 9 �1 Heating/Cooling ��" N �Domestic f 1 Monitorin �� _j__ , _..! __;__ �`. .;'� lj I ;Noncommunity PWS '�, �Environ.Bore Hole n Industry/Commercial . . p �^� �]Community PWS �J Irrigation [.;Remedial --- - -- ; � _ [[��Elevator �`j Dewatering ❑ A �' ; ; ' E� ! ASIN A . OLE DIAM. , � MA Drive Shoe7 �]Yes �No H " --�-----�--- --�-- --%-- �� i ! G�S �j Threaded ❑�ed , C ERI L '. , � � � ile i _ � teel , ��M � Plastic ❑ � --.--- -� 1 � :, ; - ,--- --;-- ---�- t\ � CASING : S Diameter Weight Specifications �i M�ie—� . � _._in.To 116 h. Ibs./ft. ____ �7 _in.To 5 V fl. PROPERTY OWNER'S NAME/COMPANY NAME in.To _ft. Ibs./ft. �� in.To_�GJ ft. ��n �1 T,.�_1 t _in.To _tt. Ibs./ft. __ in.To ft. tnJtltlCAl OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN ��0� 4.,.� f�n Make��__ _ . From__ ft. To ft. � �G Type�� Diam.� �s�� 75369 Slob'Gauze Length� Set between � ft.and it. FITTINGS`�t—� � STATIC WATER Measured rom � r � _��__ fl.' Below ��Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUM*PING LEVEL(below land surface) ^ 1�Q __ft.after__ G hrs.pumping___�_ _____g.pm. • Well/boring owner's mailing address if different than pioperty owner's a dress indicated above. WELLHEAD COMPLETION �iH� � ,�. � . (� ..�s„j:.c..._, � � � '�.Pitlessiadapter manufacturer�.1 t --�-��Q�-�� Model ______ ❑Casing protection __ _ _ _�12 in.above grade � ^I�O�QRCn:'`: ❑At-grade ��_1 Well House �_Hand Pump � GROUT INFORMATION(specify bentonite,cement-sand.neat-cement.concrete,cuttings,or other) Matenal_�ntO�teFrotmt_ � To_SQ ft. J �Yds. !`�Bags Material �tu�l 1_�c�nl_ .lt! To_��ft �__'.Yds. jJ�Bags HARDNESS OF Matenal __From To_ __ft ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _ _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��8y h� ai� a 5 - - __„_,�__, feet __� direction __-'""-""_'�'�+'�> _ type Well disinfected upon completion? �f Yes �_]No � �18y yella�r i� � 3i pUMP [�Not installed Date installed ��" san�y clay �ray soft 3I 44 �� _ Manufacturer's name San��•l$y �(�v �� t.). L[! .Model Number _. HP 1 aS Valts �� J 'f�f DCJ O/ Length of drop pipe_ <7'i� _____ ft. Capacity g.p.m. el�y��,ravel �r$}T (,#j,� �� C31 Type: -��Submersible ` l LS.Turbine � I Reciprocating []Jet I�._J ABANDONED WELLS �`�� ;ray �� 71, �,25 Does property have any not in use and not sealed well(s)? �J Yes .No VAAIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOA CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. oC/'� 1�/� The information contained in this report is true to the best of my knowledge. Use a second sheet,If�'Ay V - REMARKS,ELEVATION,SOURCE OF DATA,etc. �� MAY 0 y 201� � stoaola well nr�llin�__�OT. �_ 16"41— _ Licensee Business Name Lic.or Reg.No. . ' 3-3-16 4CIN OF ORONO �'- :r�_� epresentative"Si'gna u�e Certified Rep.No. Date t LOCAL COPY Q�Q Q�1�,� Name of Driller R�h �tOC�01� _" IC 140-0020 HE0120S15(Rev.8/13)