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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD615220 <br /> fie RnE:p 1 fi <br /> Minnesota Statutes Chapter 1031 E'9 i 9 1999 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) ateiNvrkCompleted <br /> G1TY Ur ��Dt iN <br /> Drano 118 l3 33 Sir• SW sh 81 5/-1/fiIIIII9 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 40 Truffula fraiti Orcitin ❑ Auger I[Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? C1YES ❑NO <br /> - N - <br /> . ' .9 FROM ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> iiDomestic El CommunityPWS <br /> ❑ Industry/Commercial <br /> _ _ i_ __ rigation <br /> I <br /> ❑ Noncommunity PWS ❑ Remedial <br /> W 1 ET El Test Well ❑ Dewatering C3i ,/zlM,ie CASING Drive Shoe? El El No HOLE DIAM. <br /> i i > ❑ Steel ❑ Threaded ❑ Welded <br /> XPlastic ❑ <br /> S <br /> We <br /> -- - CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 76 ft. 2[1f11bs./ft. <br /> �in.to_jj+ft. <br /> j _� _T Dev2lopmentt in.to ft. lbs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> 575 Sussex Circle Make fromPVC ft.to ft. <br /> Orono, MN 55356 Type Diam. <br /> Sen_? Length <br /> Setet between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME [z 1 ft. CjLbelow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 4 4 ft. after hrs.pumping4.(�g.p.m. <br /> WELL HEAD COMPLETION <br /> EkPiless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? [JLYes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete X High Solids Bentonite <br /> MATERIAL from to 7 ft. j ❑ yds. wags <br /> from to ft. ❑ yds. ❑ bags <br /> Clair Drown read. 0 42 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay iAUe IIled• 42 48 L 7 feet Qr t€r direction a is W �-r---Ptlrp <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed <br /> Manufacturer's name bi�2.L, rs <br /> Model number l HP l Volts �� <br /> Length of drop pipe 60 ft. Capacity j;_g.p.m. <br /> Type: ESubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Eao <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑kto <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,it needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> RES Well Drilling 27276 <br /> Licensee�ess Name Lic.or Reg.No. <br /> 00 <br /> Authorized Representative Signature Date <br /> Robtart _ stoei la, Jr. 5/7/x_ <br /> Name o/Driller Date <br /> LOCAL COPY 1615220 HE-01205-06(Rev.9/97) <br />