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UNIQUE <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTAAND BORING NO.WELL <br /> County Name WELL AND BORING RECORD 753535 <br /> Numopin Minnesota Statutes,Chapter 1037 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 118N 23W 30 '/ '/ 159 ff. August 15, 2007 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool [j Driven E)Dug <br /> F1 Auger ®Rotary [j Jetted <br /> House Number,Street Name,City,and Zip Code of <br /> Well tcLocation <br /> or Fire Number 111140 Sart Lias Rd, Maplfs Plain DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. water From ft.To ft. <br /> Showing property lines, <br /> N roads,bg and dire n. USE <br /> �T Domestic ❑monitoring ❑Heating/Cooling <br /> _:_____�____ _..1__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> --i-----i----- -----_-- Elevator ❑Dewatering ❑ <br /> N e CASING OLE DAM. <br /> --;-----�-------- <br /> C G MATERIAL Drive Shoe? ❑Yes �]No H <br /> h Mile w... Welded <br /> Steel �Th ded <br /> 1 T , <br /> ®Plastic ne <br /> T n <br /> CASING <br /> s Diameter Weight Specifications <br /> —1 Mile 4 in.to 154 ft. lbs./ft. $I in.to 40 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. _ '_ in.to 159ft. <br /> Diesen Development in.to ft. lbs./ft. in.to ft. <br /> OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN i <br /> 1100 ToWn Line Rd Make ism From ft. To ft. <br /> Maple Plain, MN 55359 Type �C Diam. <br /> SIo/Gauze tt Length <br /> Set between 154 ft.and 159 ft. FITTINGS k packer <br /> STATIC WATER LEVEL grade <br /> M Measured from <br /> 100 ft.91 Below [IAbove land surface Date measured 8-15-0 _ <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> Diesen Developaent ft.after hrs.pumping 401 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 Maass Model 4 <br /> ❑Casing Protection ❑12 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes ❑No <br /> Grout materials ❑Neat cement ®Bentonite ❑Concrete ❑Other <br /> From 4 To 40 ft. 3 ❑Yds. :R Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. ❑Yds. [:]Bags <br /> MATERIAL From To ft. ❑Yds. ❑Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATIONpver 50 the <br /> from ner <br /> clay yello'v 0 37 <br /> t feet direction type <br /> Clay gray 37 Well disinfected upon completion? Yes ❑No <br /> A PUMP <br /> sand gray 90 105ElNot installed Date installed J{� L, <br /> Manufacturer's name A A `E <br /> l <br /> clay & sand brawn 105 145 Model Number HP� Volts <br /> — ! Length of drop pipe V ft. Capacity 1 r g.p.m. <br /> Sand 4 gravel sized 145 159 Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes 191 No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes :91 No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> Use a second sheeeded. The information contained in this report is true to the best of my knowledge. <br /> et,it n <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Stevens Drilling & Env. Svc, Inc. 2255 <br /> LicGrlsee Business Name Lic.or Reg.No. <br /> 86654 9/16/20W <br /> Ce ified Representative Signat a Certified Rep.No. Date <br /> Mike LOCAL COPY / 53 5 3 5 Stevens <br /> Name of Driller <br /> IC 140-0020 <br /> HE-01205-10(Rev.6/06) <br />