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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL RECORD '� ty�-+�
F{ennepi n Minnesota Statutes Chapter 1031 �� '� � � F-� �
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Orono 117N 23W ��32 SE,,.SW,, NW ,,, � 132 "� 11/34/93
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
480 Deborah Dri ve ❑ Cable Tool � Driven ❑ Dug
❑ Auger ❑ Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map o(well location. ❑
Showing property lines,
ry roads and buildings. DRILLING FLUID
I � _1 _1_
--�--,- , , None
i � i i ,USE �Domestic ❑ Monitoring � Heating/Cooling
�-+- �-- �- �- � Industry/Commercial
W 'X ; � E ❑ Irrigation ❑ Public
_1_ _1_ __ __ T ❑ Test Well ❑ Dewatering � Remedial
� � i �
�""'� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
--�- �- ; -r- I �Steel ❑ Thre�q:�.Q ❑ Welded
' 1 Plastic ❑ ���
�—1 mife�
CASING DIAMETER WEIGHT o
PROPERTY OWNER'S NAME 4 in.ro 1�7 ft. Ibs./fl. v� in.tol`�2ft.
Michael Pierce ��.to ft. Ibs./R. in.to n.
Mailing address if different than property address indicated above. in.to ft. __Ibs./ft. in.to fl.
480 Ueborah Dri ve SCREEN OPEN HOLE
Miaple Pidin� i��n. 55359 Make � from �.�o �.
� Type �� Diam.
SIoUGauze � Length 5�
Set between ft.and ft. FITTINGS:
STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO #.3 ft.� below ❑ above land surface Date measured
MATERIAL
PUMPtNG LEVEL(below land suAace) t
C 1� Yel�O�P/ O 1$ ft. after hrs.pumping �`� g.p.m.
C �W�EtLL HEAD COMPLETION
Clay Gray 18 VO IJF'itlessadaptermanufacturer ��SS Model ���
❑ Casing Protection ❑ 12 in.above grade
Clay& Sand Gray 60 �V� GROUTINGINFORMATION
Well grouted? �I Yes ❑ No
Sand & Gravel Mixed 105 132 Grout Material � Neat cerp�nt ❑ Bentonit(g�
from V to 3`� ft, ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
feet direction type
Well disinfected upon completion? C�Yes ❑ No
PUMP
� � ❑ Not installed Date installed ��`���Q�
- � Manufadurer's name
Model number HP Volts
Length ot drop pipe � ft. Capacity g.p.m.
Pressure Tank Capacity
MAR + ��� Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
.
. �^ ^ r1A t n
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes �I No
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,il needed __��eYGIIS ���� ori 11 i na Ca I n� r��5634
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name � � Lic.orReg.No.
Authorized Representative Signature Da e
Dri Date
LOGF�L COPY 5 3 0 2� � HE-07205-04(Rev.S/92)