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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MtNNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 9 5 6 4 3 <br /> $eAneF�n Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 1.17N 23W 17 ,� ,� ,� 167 " 12-30-03 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees __ minutes seconds _ <br /> ❑CableTool Driven �j Dug <br /> Longitude degrees minutes __ seconds " ,,�quger `�Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �, <br /> 1625 Btihns Paint R.d� OI�OAO SS341 DRILLING FLUID WELL HYDROFRACTURED? J Yes I� No <br /> Shop exact location of well in section grid with"X". Sketch map of well location. �a�er <br /> � property lines, FROM tt TO ft <br /> N tS.�,/ (/�-�, roa and bui�dings USE � ;Monitoring ❑Heating/Cooling <br /> ' � �� `��t �� �omestic �.j Environ Bore Hole �Industry/Commercial <br /> :. --' --'-- - ` `- <br /> �( /. �,J Noncommunity PWS �_�Irngation ��'�Remedial <br /> ��%� "Y"' J Communiry PWS [_�Dewatering �' <br /> L: <br /> ""''----'--- --`-"'-"�-- ASIN OLE DIAM <br /> C G H <br /> . W � I I I E Drive Shoe? L���Yes �No <br /> - , <br /> , <br /> � � � � e e <br /> " --;-----�-- —�-- ' � 7 Id d <br /> ____ T ., ❑Steel [_;Threadgd �]W <br /> 'h M�ile � f.�J.+7�,�� PI25tiC lue.' <br /> -. � � � � � '' ' <br /> ------ ------ ------------ 1 <br /> CASING DIAMETER WEIGHT <br /> S 1 <br /> , , , � ��.to 252 ft. Ibs./ft. $� ��.to '�5 n. <br /> F-1 Mile-� 6 167 <br /> in.to R. Ibs./ft. �in.to _ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to tt. <br /> Pillar HO�C8 SCREEN OPEN HOLE <br /> Property owner's mailing address if different than weil location address indicated above. Make___ S�C�. FROM ft. TO ft. <br /> 125 Lake .Str@@� W TYPe �Ci Diam. _ — <br /> SIoUGauze__ �� Lengih� ��� :: <br /> Wayzata, MN 55391 Set between Ib2 ft.and 167 ft. FITTINGS kpacker <br /> STATIC AWATER LEVEL <br /> �V ft.�below '�J above land surface Date measured__ 12�3���3 _ <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> Pillar Ad$�$ _ft.after _ hrs.pumping 1��' g.p.m. <br /> WELL HEAD COMPLETION tK <br /> Well owner's mailing address if different than property owners address indicated above. �itless adapter manufacturer_ M�ag Model_ `� _ <br /> Casing Protection_ �02 in.above grade <br /> ^�At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION - <br /> Well grouted �Yes [--1 No <br /> Grout material �i J Neai cement '��,�entonite �]Concrete ['�..High Solids Bentonite . <br /> from� 6 to �5_ft. 3 ❑Yds. �bags ' <br /> from. . to fL �, I yds. '�_���bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO � from_ to ft. '`I yds. I�"I bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> C.18 j pe l lu�r Q 1 g _ feet _ __ direction rype <br /> Well disinfected upon completion �Ves �I No <br /> Cil.11�I gray is f�� PUMP �, <br /> !�_]Not installed Date installed����`�'� � <br /> Ci1.8�► bt $8Dd g78�t �y� �d Manufacturer'sname �" '�l'�.�✓�—.-• <br /> Model number__ HP_�Volts <br /> Sandwery f iae tan 70 153 (�f�� at U <br /> Length of drop pipe tt. Capacity _g.p.m. <br /> sand � Y'$VB� 1��@a 1�q �C� Type: Submersible i�LS.Turbine [ Reciprocating r'Jet ` _ _ <br /> ' K •� � ABANDONED WELLS � � <br /> Does properry have any not in use and not sealed well(s) � Yes � o <br /> � - VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes ' �No TNit <br /> WELL CONTRACTOR CERTIFICATION <br /> � This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The informa�ion contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed <br /> REMARKS,ELEVATION.SOURCE OF DATA,eta SCEVEIIH Dri.11�A 6 Ennironmental Svc 8b6S4 <br /> --- �---- ---- <br /> Licensee Business Nam Lic.or Reg.N�. <br /> :,� �\` ,, _ _y �� �(.( <br /> ; , _ � � <br /> Authorized Representative Signature Dat + <br /> � Randy Johnaon 1��,���f /�:� <br /> ; 6 9 5 6 4 3 Name of Driller Date <br />" � LOCAL COPY He-o,zo5-os�ae�.sioz� ? <br /> iC iao-oozo <br />