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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTAAND BORING NO.WELL
County Name WELL AND BORING RECORD 753535
Numopin Minnesota Statutes,Chapter 1037
Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
Orono 118N 23W 30 '/ '/ 159 ff. August 15, 2007
GPS DRILLING METHOD
LOCATION: Latitude degrees minutes seconds
Longitude degrees minutes seconds ❑Cable Tool [j Driven E)Dug
F1 Auger ®Rotary [j Jetted
House Number,Street Name,City,and Zip Code of
Well tcLocation
or Fire Number 111140 Sart Lias Rd, Maplfs Plain DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No
Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. water From ft.To ft.
Showing property lines,
N roads,bg and dire n. USE
�T Domestic ❑monitoring ❑Heating/Cooling
_:_____�____ _..1__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
❑Community PWS ❑Irrigation ❑Remedial
--i-----i----- -----_-- Elevator ❑Dewatering ❑
N e CASING OLE DAM.
--;-----�--------
C G MATERIAL Drive Shoe? ❑Yes �]No H
h Mile w... Welded
Steel �Th ded
1 T ,
®Plastic ne
T n
CASING
s Diameter Weight Specifications
—1 Mile 4 in.to 154 ft. lbs./ft. $I in.to 40 ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. _ '_ in.to 159ft.
Diesen Development in.to ft. lbs./ft. in.to ft.
OPEN HOLE
Property owner's mailing address if different than well location address indicated above. SCREEN i
1100 ToWn Line Rd Make ism From ft. To ft.
Maple Plain, MN 55359 Type �C Diam.
SIo/Gauze tt Length
Set between 154 ft.and 159 ft. FITTINGS k packer
STATIC WATER LEVEL grade
M Measured from
100 ft.91 Below [IAbove land surface Date measured 8-15-0 _
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
Diesen Developaent ft.after hrs.pumping 401 g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
Pitless/adapter manufacturer Maass Model 4
❑Casing Protection ❑12 in.above grade
❑At-grade(Environmental Well and Boring ONLY)
GROUTING INFORMATION
Well grouted Yes ❑No
Grout materials ❑Neat cement ®Bentonite ❑Concrete ❑Other
From 4 To 40 ft. 3 ❑Yds. :R Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. ❑Yds. [:]Bags
MATERIAL From To ft. ❑Yds. ❑Bags
NEAREST KNOWN SOURCE OF CONTAMINATIONpver 50 the
from ner
clay yello'v 0 37
t feet direction type
Clay gray 37 Well disinfected upon completion? Yes ❑No
A PUMP
sand gray 90 105ElNot installed Date installed J{� L,
Manufacturer's name A A `E
l
clay & sand brawn 105 145 Model Number HP� Volts
— ! Length of drop pipe V ft. Capacity 1 r g.p.m.
Sand 4 gravel sized 145 159 Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes 191 No
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes :91 No TN#
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
Use a second sheeeded. The information contained in this report is true to the best of my knowledge.
et,it n
REMARKS,ELEVATION,SOURCE OF DATA,etc.
Stevens Drilling & Env. Svc, Inc. 2255
LicGrlsee Business Name Lic.or Reg.No.
86654 9/16/20W
Ce ified Representative Signat a Certified Rep.No. Date
Mike LOCAL COPY / 53 5 3 5 Stevens
Name of Driller
IC 140-0020
HE-01205-10(Rev.6/06)