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:.;'�� �. <br /> k <br /> M/NNESOTA UN/QUE WELL <br /> WELL«OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD ` <br /> �enne in <br /> Minnesota Statutes,Chapter 10.3I 8 2 7 8 4 8 <br /> Township Name Township No. Range No. Section No. Fraction(sm.--.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 11� 23 25 �F NW� SE �� 487 " 11—Ifrl�: <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ��Driven J Dual Rotary <br /> ❑Auger �Rotary � !�Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> l lp� �iW�C�C I�L, C�COT]O 5 �j DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> t;7i_7 ���V!!1�e <br /> Show exact location of well/boring in section grid ith"X" Sketch map of well/boring location. From ft.To ft. <br /> Showing property lines, <br /> ; • roads,buildings,and direction. USE <br /> N � �Domestic [_�',Monitoring [�Heating/Cooling <br /> �� � � � � `�� ,�Y � ❑Noncommunity PWS �� �Environ.Bore Hole [�Industry/Commercial t <br /> ��. --'-- --'--- --`-- --'-- '� ' <br /> - i .,�+9 [;Community PWS �]Irrigation �Remedial <br /> '`' --'----;--- --`-- ---`-- � Dewatering - <br /> , T � � <br /> , y �� []Elevator (� <br /> � w ' ; ; ; E /\; CASING MATERIAL Drive Shoe? �Yes ��`]Na HOLE DIAM. <br /> � � � \ <br /> .. --�-----�-- --F-----:- '. <br /> . '�Steel []Threaded �Welded <br /> '. --�-----�-'-"„-"-;-- ile - - <br /> ��M � L]Plastic [] <br /> 1 _.,� <br /> � � CASING <br /> S � � �, Diameter Weight Specifications <br /> � 4 46Q 1� 7e AS3� R !�6iJ <br /> i 1 Mile� in.To ft. • �lbs./ft. in.To ft. <br /> PROPEFTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �in.To "'" ft. <br /> in.To ft. Ibs./ft. in.To ft. � <br /> Property owner's mailing address if different than well location address indicated above. �p �gp <br /> SCREEN OPEN HOLE <br /> Make ��� Frofl+� ft. To �X'.�� ft. <br /> 6I17 �ilu� Crl Dr, Ste 101 Type stain ess stee Diam. <br /> Micmekonka, �''�AT 55343 SIoVGauze�0 Length�Q� y ____ <br /> Set between({��'i ft.and it FITTINGS <br /> STATIC WATER LEVEL 1�� ft.�'Below [�Above land surface <br /> t <br /> Measured from � __ � e measured____._ .+ ry hole 'u Yes o � <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> �� ft.after hrs.pumping g.p.m. <br /> - Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer;,��te���s� Model <br /> ❑Casing protection �f 12 in.above grade <br /> ❑At-grade r]Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material��e�Ecocn�__To l.Gt� ft. � C Yds. �]Bags <br /> I I� —�3�� 9� <br /> Matenal From To ft. �Yds. I�Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags 9- <br /> One ba 94 Ibs.cement <br /> or 50 Ibs.bentonite <br /> Cl�j� hr(�{� �� � � NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ,: +.-' � Wellis�.$�.._ __ feet � ..___ directionfrom��jt� _ type ;�� <br /> �[Sne� �(.,+��^n,J�� jT}iX r� (��7 R'Z Well disinfected upon completion? es ❑No <br /> ,,T PUMP <br /> SaTl{�}T Cle�jl �ray ij]Jn �,l�j 1�'rj ❑Not installed Date installed_ ��"�?"`O <br /> +7 Manufacturer's name �iltte2�t� '� <br /> 3Atl�y Cl�y �;ray SO�t ?Zf; 370 Model Number HP�voit5 <br /> ��7 t�G Length of drop pipe 7�n ft. Capacity g.p.m <br /> .�iatriij� C18� ciark br (I��LVfI 3�� �7J Type: Submersible ❑LS.Turbine ❑Reciprocating �Jet [J <br /> �� ABANDONED WEL�S <br /> 1 f Yn�� ,�ink r� 423 �`�t3 Does property have any not in use and not sealed well(s)? ❑Yes o <br /> k j VARIANCE <br /> shale Uray/gr tili�d 485 "i`J7 �n/as a variance granted from the MDH for this well? �Yes o 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 /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> F�on Stodola t�ell Drilli Co. Inc. <br /> Licensee Business Name Lic.or Reg.No. <br /> % <br /> �� �� �.�'�J�d�ZC� <br /> JL <br /> Geitifi�A'�t es ntative Signature Certified Rep.No. Date <br /> ' LOCAL COPY !�i*�nes 3�.ier/Anc�r�r I.andcy S� Phi1 �offin� <br /> $2 7 8 4 8 Name of Driller <br /> ID#52603 HE-01205-16(Rev.5/16) <br /> � <br />