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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 3 913 0
gQIlI1e i n Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WEIL DEPTH(completed) Date Work Completed
n.
Orono 118 23 32 ,. ,. ,. 198• 12-23-99
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
d 5539 i � Cable Tool ❑ Driven ❑ Dug
3675 Jacobs �111. Boad Oroao, � ❑ Auger �[Rotary ❑ Jetted
Show exact location of well in section grid with"X". • L Sketch map of well location. ❑
M � ing property lines,
fj�pB� I'"� roads and buildings. DRILLING FLUID t WELL HYDROFFACTURED? G YES ❑NO
N �DLODit� FROM R.lo ft.
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_i _i_ _i_ _i_
USE �R ❑ Monitoring ❑ Heating/Cooling
i � � i 4` p Domestic ❑ Community PWS ❑ Industry/Commercial
_i_ _�_ _�_ _i_ ❑ Irrigation
� � i i �f ❑ Noncommunity PWS ❑ Remedial
yr E T ❑ Environ.Bore Hole ❑ Dewatering ❑
i i i i I
-r -�- -r- -r
i i i i +/ZM.ia CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
i _ �_ _L_ i � ❑ Steel ❑ Threaded ❑ Welded
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�Plastic ❑
s
�-t Mile-�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �__in.to_�Z ft. SDBZ1 Ibs./ft. I�� 3QE.
Jsf f 1ls�at ;�.to h. Ibs./ft. in to 198.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to tt.
SCREEN OPEN HOLE
�QI S 1 Bt Make�.ohnsoa from ft.to ft.
Kin:teapolis, �• g540 Type Diam M
SIoUGauze�l A_A1 A Length 4� + 4�
Set between �,�_�ft.and198 ft. FiTTINGS:
STATIC WATER LEVEL
WELL OWNER'S NAME Qg� ft. �elow ❑ above land surtace Date measured� 9
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. �A 5� ft. after I hrs.pumping 30 g.p.m.
WELL HEAD COMPLETION �,a:
�Pitless adapter manufacturer ��t.e�a y� Model
❑ Casing Protection _.__ �12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �Yes ❑ No
HARDNESS OF Grout Material ❑ Neat ce�ent �Bentoy�t� ❑ Concrete � igh Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
from to j ft. ❑ yds. �.bags
F��� c w* �Q from to ft. ❑ yds. ❑ bags
,i �'� from to ft. ❑ yds. ❑ bags
NEARE f W1J SOURCE OF CONT INATI(� �`��
Cl$Y TQll�� s 1� 25 feet nCJ 1 �/ direction �..:�.- ���rype
Well disinfected upon completion? �Yes ❑ No
Clay Grey S 25• 90 pUMP
❑ Notinstalled Dateinstalled Z�27�00
Sand aravel HrO� � 90, ���,Manufacturer'sname ��ar`te
Cldjt-GIaYl1 BIOI►11 S �34• 185�Model number 1 6 HP 1 vo15 23� 0
.
Length of drop pipe ft. Capacity.. g.p.m.
CDar�e 5•8n� ye110� S 1 p:7� 1 A7�Type: �ubmersible ❑ L.S Turbine ❑ Reciprocating ❑ Jet ❑
i 7
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes �7 No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes �I No TN#
WELL CONTRACTOR CERTIFICATION
Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is lrue to the best of my knowledge.
DON STODOLl� �+IELL DBILLING CO. . INC.
_ Licensee iness Name i� , Lic.or eg.No. �''1'12
�� 3-2-00
_
Authori2ed� entative Sign ture -�' Date
Fred Leiby 12-23-99
6 3 913 0 Name o�Oriller Date
LOCAL COPY HE-01205-07(Rev.2/99)