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� <br /> r - <br /> , � <br /> MINNESOTA UNIQUE WELL <br /> WELUBORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> : co��tY Name WELL AND BORING RECORD 7 3 917 4 <br /> � �n Minnesota Statutes,Chapter 103I <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> � Orono 127 23 10 ��a ��a ��a 295 n 9-6-46 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds ._ <br /> i Cable Tool Driven I7 Dug <br /> Longitude degrees minutes__ seconds _�Auger �otary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number <br /> ��� � � C AV� Or�no 55323 DRILLING FLUID � WELL HYDROFRACTURED? f.!Yes -. .o <br /> Show exact location of well/boring in section gr' with"X." Sketch map of well location. �t�t� <br /> � Showing properry lines, From tt.To ft. <br /> � USE . omestic ❑Monitoring �f'Heating/Cooling <br /> N roads,buildings, <br /> - �� and direction. i '�Noncommunity PWS !l�Environ.Bore Hole i I Industry/Commercial <br /> ��:� --'--- --'-----`-- ' ' WS I � f <br /> --- -- � � .Communiry P 17 rriga ion � �.Remedial <br /> � I I Elevator _!Dewatering _I <br /> --'--- --'-----�--- ---'-- CASING M�A/T�ERIAL Drive Shoe? es I �No HOLE DIAM. <br /> W E T ��� � � ip�teel �KThreaded ._�Welded <br /> I '�7 Plastic <br /> : , ; ' '/z Mile � ". <br /> , ; j ; j � � CASING �� <br /> --�--- --'-----�— --•_ s <br /> Diameter Weight Specifications <br /> S qt Q <br /> �1 Mile� '�y�J,� � ,`� � in,to_Z�_. ry. li _ Ibs./ft. �� `�' in.to_ �ft. <br /> � �j <br /> __in.to____._ft. _._. Ibs./ft. �__in.to_�!�ft. <br /> 4:� PROPERTY OWNER'S NAME/COMPANY NAME )p ry�C <br /> in.to ft. Ibs./ft. __, _�7L47in.to�ft. <br /> ` �(.`[�pC1 11{3(1[1,LE SCREEN OPEN HO+L}E <br /> ? Property owner's mailing address if different than well location address indicated above. Make From `� ft.To —I I ft. <br /> Type Diam. <br /> SlotlGauze Length <br /> Set between ft.and - fl. FITTINGS <br /> STAT}I,C�WATER LEVEL <br /> �+ __ft.�Below I 1 Above land surface Date measured � " "" <br /> PUMPING LEVEL(below land surface) <br /> WELUBORING OWNER'S NAME/COMPANY NAME [ <br /> _. ��! ft.after_� hrs.pumping_� g.p.m. <br /> �L HEAD COMPLETION � -- <br /> Well/boring owner's mailing address if different than property owner's address indicated above. itless Adapier Manufacturer ���del <br /> �. i Casing Protection . �12 in.above grade <br /> �_At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION�,( <br /> . Well grouted? �l'Yes -No <br /> Grout materials I I Neat cement�entonit�f,,;Concrete ��.--�..O�r �� <br /> From To `�j ft. '. �Ytd's. I I Bags <br /> From�To�ft. ���� I��cfF� ��. �Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. I �.Yds. '�. '�Bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> tO �s� Ll�y �t� Q L •J feet � direction`�-"y"'� ��'�``"'�"r't4'�72' , <br /> 1 Ul Il 1 � Well disinfected upon completion? I�Yes l_l No _1_�,,,�� a <br /> t e� PUMP <br /> "�'� v�� `��� � G�''.Not installed Date installed " +� G� <br /> C�$ � r� �ct �� n Manufacturer's name <br /> a G ��� <br /> Model Number HP /�� Volts <br /> �1 �Qft 2,7V 27 Length of drop pipe /O� ft. Capacity_ _ g.p.m. <br /> Type:� ubmersible i,LS.Turbine �"-!Reciprocating !_'��Jet ❑ - <br /> fi $ll��e b� .�tt 276 � ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)7 , �es ,�lo � <br /> � L�{� ZgU 'l(�S VARIANCE <br /> Was a variance granted from the MDH for this well? _!Yes '�Mf(Vo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> i <br /> Use a second sheet,if needed. 7�� c T <br /> - REMARKS,ELEVATION,SOURCE OF DATA,etc. 1�i711 �7co�oia �ei� �c�.�i� co�� 1�. 169! <br /> � ---- — --— <br /> ' � �Sj nn �f�L_AAL Licensee Business N me �Lic.or Reg.No. � <br /> � i..a !. {T60V <br /> : _.�-�""'^e � <br /> t ' f �y /(�-V�L.� .'-. <br /> iori ed epresentative Sig re Date <br /> �il{ll:lt t'�� <br /> LOCAL COPY 7 3 917 4 Name of Driller r <br /> HE-01205-09(Rev.9/05) <br /> IC 140-0020 <br />