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MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. WELL AND BORING RECORD 591098 Rennet In Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n Orono 117 285 ' _16,-9 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug 4750 Northshore Dr. Orono, Mn. rJ564 ❑ Auger Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ Showing property lines, DRILLING FLUID N tl✓6y� Bentonite USE ❑ Monitoring ❑ Heating/Cooling Domestic Irrigation EI Community PWS ❑ Industry/Commercial ❑ Noncommunity PWS ❑ Remedial WET ❑ Test Well [I Dewatering ❑ ,/2M1e CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. ❑ Steel ❑ Threaded 17 Welded :C Plastic ❑ -1 Mile CASING DIAMETER WEIGHT / PROPERTY OWNER'S NAME _ C n.to G 7 6 n. SDR•2 1 lbs./ft. z�7;R. mes Thornson in.to t§�t 1. JAff. lbs./ft. V tidtb 2$f Property owner's mailing address if different than well location address indicated above. - __ in.to ft. lbs./ft. in.to _ft. SCREEN OPEN HOLE Make Johnson from ft.to ff. Type Stainless Steel Diam. Slot/Gauze Length 2" _ Set between ff.and 2 R ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME 12,Ci ft.X below ❑ above land surface Date measured i� 1--E _9 ' PUMPTtl,,LEVEL(below land surfaeM, Well owner's mailing address if different than property owner's address indicated aboveft. after d hrs.pumping 19 g.p.m. ELL HEAD COMPLETION Whitewater m.., adapter manufacturer Model ❑ Casing Protection 5{❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? X Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material El Neat cement XU Bentonite ❑ Concrete Exigh Solids Bentonite MATERIAL fromf�r to 3 0 ft. ❑ yds. R bags VellGi from to f. ❑ yds. El bagsL y � from to ft. _ ❑ yds. ❑ bags -1 NEAREST KN ANN SOURCE OF CONTAMINATION �f Clay Grey S '30 1 115 0 feet �e�c1 j N direction � (, type 7r �c C Well disinfected upon completion? '[I Yes ❑ No Sand TFn �� 115 ' 148 PUMP l_1 J_ ' El Not installed Date,inst ed Clay Grey `3 146 Manufacturer's name Rei �.acyat- - Model number 0 b 9 7 5 i 6 HP 3/4 Volts 2 31?, F'I ne SdriU n 1801 1 9 61 Length of drop pipe 146 ft. Capacity 1 0! c.p.m. Pressure Tank Capacity PC 12 L Type: submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet [Igilt Grey S �3C) ' 2t�t'+ ' ABANDONED WELLS Course Sand Tan $ 4,1$0 ' 2S5 Does property have any not in use and not sealed well(s)? ❑ Yes X❑ No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes IXNo WELL CONTRACTOR CERTIFICATION Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. REMARKS, DON STODOLA WELL DRILLING CO. , INC. Licensee Business Name Lic.or Reg.No. 2 7T-72 �f 1-16-98 fid''Authorized Represents iv�nature Date Fred Leiby 2-16-9i3 f Name of Driller Date LOCAL COPY 591098 HE-01205-05(Rev.1/95)