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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORDamnevin a <br /> Minnesota Statutes,Chapter 1031 F 7 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> H. <br /> 'G <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> ❑Auger Rotary ❑Jetted <br /> House Numb Street Name,City,and Zip Code of Well Location jor Fire Number ❑ ' <br /> N=h ShOM Dr W. Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X10 <br /> ow exact location of well in section grid with"- ". Sketch map of well location. wat c FROM ft.TO ,/` ft. <br /> Showipg property lines, <br /> N (� lu6ds and buildings USE El <br /> �1 Monitoring ❑Heating/Cooling <br /> __;_____;_____;__ ;__ '-} Domestic E]Environ.Bore Hole ❑Industry/Commercial <br /> Noncommunity PWS ❑Irrigation ❑Remedial <br /> Community PWS ❑Dewatering <br /> ❑ <br /> - t ^Comm <br /> CASING HOLE DIAM. <br /> W E Drive Shoe? [I Yes 4,,1#N0✓ <br /> ❑Steel El Threaded 11 Welded <br /> Mile Plastic <br /> ❑ <br /> r --------- 1 <br /> \ ---""'J��• CASING DIAMETER WEIGHT <br /> 1 s 1 \l <br /> ��- i in.to M ft. 2.41 lbs./ft. in.to 30 ft <br /> —1 Mlle { . <br /> in.to ft. lbs./ft. in.toi <br /> PROPERTY OWNER'S NAME/COMPANY NAirE in.to ft. lbs./ft. in.to ft. <br /> Un-Agrp-nSCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make% <br /> TFROM <br /> . TO <br /> ft. <br /> 545 Indian Mound E Type stl Dia <br /> SIoUGauze Length 41 44,Layz55391 <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL <br /> 10 -ft. elow ❑above land surface Date measured 4— <br /> WELL OWNER'S NAME/COMPANY NAME <br /> PUMPING LEVEL(belAt land surface) <br /> 19�y0 <br /> ft.after 2 hrs.pumping 95 g.p.m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. y�—�y�'/p'ltless adapter manufacturer �.temitet Model <br /> {�Casing Protection in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) T <br /> GROUTING INFORMATION <br /> Well grouted es E]No <br /> Grout material Neat cement <br /> L]Bentonite ❑Concrete�igh Solids Bentonite <br /> from to 30 ft. ❑yds. 1Aags <br /> from to ft.�ilii C bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. _ <br /> MATERIAL ❑yds L-bags <br /> NEARESTKNOWNSOURCE OF CONTAMINATION <br /> feet 1V Ziirdirection type <br /> Well disinfected upon completion es ❑No <br /> PUMPclay soft 2n -80- <br /> y��tt <br /> ❑Not installed Date installed <br /> 4-4 <br /> Msand - gray sof r An 17nanufacturer's name <br /> Model number HP I j Volts <br /> clay r. Length of drop pipe 1,471 ft. Capacity 9— <br /> p.m-Type:56ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> sandigravel -Rnfr155 2MABAINPONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes 0 <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes o TNk <br /> WELL CONTRACTOR CERTIFICATION If <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 /> We!- 27172 <br /> Licensee Business Name o. <br /> 5-4-04 <br /> o epr en at/ve Signat/+�,,,��k y�,� 4-2&-04Dattee <br /> LOCAL COPY_ 705941 <br /> 059 1 Name of Driller <br /> ., <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />