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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH RECEIVED MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Hennepin Minnesota Statutes Chapter 1031 0 3 20 692845 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 11711 2311 S 511,11E / 122 Y V�ORONO 9—"3 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven Dug <br /> i�I Auger Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �l <br /> 205 Tanta ATI, Orono 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes NNo <br /> Shop exact location of well in section grid with"X". Sketch map of well location. Muer FROM ft.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE ❑Monitoring ❑Heating/Cooling <br /> XDomestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Noncommunity PWS ❑Irrigation ❑Remedial <br /> ❑Community PWS ❑Dewatering ❑ <br /> -------- ----- - --`-- ? <br /> CASING HOLE DIAM. <br /> w ET � Drive Shoe? ❑Yes No <br /> Steel ❑Threaded Welded <br /> 'h Mile Plastic 1. <br /> -------- -- 1 <br /> CASING DIAMETER WEIGHT <br /> S 4 in.to 117 ft. lbs./ft. al—in.to 45 ft. <br /> 1 Mile t �� <br /> in.to ft. lbs./ft. y;_in.to 122 <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> in.to ft. lbs./ft. in.to f <br /> Ti: & Natalie Vaughan SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make IYCO FROM ft. TO ft. <br /> 425 Dexter Drive Type "C Diam. <br /> Long Late, MPI 55356 Slot/Gauze Length 5 <br /> Set between 117 ft.and 122 ft. FITTINGS k"cker <br /> STATIC WATER LEVEL ��9_-_-p9�-0� <br /> 62 ft. below [I above land surface Date measured___ i3]t111i�i <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> Tia & Natalie Vaughan ft.after hrs.pumping 50+ g.p rn <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. )(Pitless adapter manufacturer Naals Model__■ <br /> ❑Casing Protection 12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted A Yes ❑No <br /> Grout material ❑Neat cement Apentonite ❑Conc►ete ❑High Solids Bentonite <br /> from 6 1 to 45 ft. 3 ❑yds. %bags <br /> from to ft. _ ❑yds. ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. ❑bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CQNTAMINATION <br /> Wk?riGtilrr �U� rlJYY ; 1..4JP✓� <br /> Clay Yellow 0 30 _feet direction type <br /> Well disinfected upon completion Yes ❑No <br /> Clay Gray 30 80 PUMP /� f <br /> ❑Not installed Date installed <br /> Gravel & Sand Mixed 80 122 Manufacturers name A4.j j ee <br /> Model number / HP Volts <br /> Length of drop pipe r✓ ft. Capacity g.p.m. <br /> Type:XSubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes )QNo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes X No 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 7 Em1 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Stevens Drilling rirommutal $TC 86654 <br /> Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Bandy Johnson /0 " -1 ,,—,/I--'Z, <br /> LOCAL COPY � 692845 Name of Driller Date <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />