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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 633587 <br /> Henne. i a Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 5 SW,,, SW 'tri, n <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> R 3.30 'Tonka Ave. Orono ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> C Showing property lines, - - - -- <br /> V roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES CCNO <br /> N <br /> Paroid "uik el FROM -ft.to ft. <br /> USE El Monitoring <br /> ElHeating/Cooling <br /> l Domestic ❑ Community PWS <br /> J{.µw .� Y ❑ Industry/Commercial <br /> G -�,_ ,-// ❑ Irrigation ❑ Noncommunity PWS <br /> w i i E j �f f ❑ Environ.Bore Hole y El Remedial <br /> El Dewatering ❑ <br /> /2M_18 1 B CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> ;k7 Plastic ❑ <br /> s <br /> CASING DIAMETER WEIGHT 1 <br /> PROPERTY OWNER'S NAME �' in.to 91 ft. 1 .9 lbs./ft. in.`� <br /> Co� ft. <br /> Fill 1. U '✓!?r --in.to ft. lbs./ft. L�3 in. o �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 /> Make c r e s l lie from ft.to ft. <br /> Type j,%l a c t i c Diam. 11 <br /> Slot/Gauze 1 5 Length 1 O f f <br /> Set between -3 1 ft.and 1 01 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 30 ft.A below ❑ above land surface Date measured 1/27 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping 40 g.p.m. <br /> WELL HEAD COMPLETION <br /> -)t Pitless adapter manufacturer DIY h.i t ed a t e r Model sit 4 5 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? `L Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 1 Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete CCHigh Solids Bentonite <br /> MATERIAL <br /> from -10 to 0 ft. 7 ❑ yds.7L"1 bags <br /> black dirt black s o f t Q 1 3 from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN <br /> NSOURCE OF CONTAMINATION <br /> c1� Ygray yUf t 13 �1 © <br /> feet 'west direction Citi hype <br /> - - -•- Well disinfected upon completion? m Yes ❑ Nosewer <br /> sant. & ciay gray- - Salt_ 61 87 PUMP <br /> ' '---•------_.... ❑ Not installed Date installed <br /> sand -�,ra'�------ _sof._t 87 101 Aero or <br /> -" -•-- - Manufacturer's name �- <br /> 1/2 220 <br /> -•^� .^ -.-~-_ Model number ._HP V1 V Ij5 <br /> ~ - '""` Length of drop pipe ft. Capacity g.p.m. <br /> -•-.. Type: A Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> _ ASAWONEV XVgLL_S 5yc <br /> Does property have any not in use and not sealed well(s)?- El Yes LY No <br /> _..`.. VARIANCE._.... <br /> Was a variance granted from the MDH for this well? ❑ Yes 1�No TN# <br /> WELLCOWRACTORCERTIFICATION <br /> Use a second sheet,if 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 cwtained in this report is true to the best of my knowledge. <br /> Leuthner Well Inc. 10125 <br /> Licensee Business Name, Lic or Reg <br /> _ - - 6 <br /> uthonzed Re sentative Signature ate <br /> Maurice L. Leuthner 3/2/00 <br /> LOCAL <br /> �/ Name of Driller Date <br /> LOCAL COPi 1633587 HE-01205-06(Rev.7/98) <br />