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MINNESOTA UNIQUE WELL <br /> WELL OR RARING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> WELL AND BRING RECORD <br /> County Name 7 0'6 2 yam" <br /> Minnesota Sues,Chapter 1031 6Ohl hV <br /> Township am Township No. Range No. Section No. Fraction WEI/BORING DEPTH(cgmpleted) DATE WORK COMPLETED <br /> Orono 117 23 01 v i28 " b-3-€' <br /> GPS <br /> LOCATION: Latitude degrees minutes seconds <br /> DRIl7NG METHOD <br /> �",:❑Cable Tool r ❑Driven L]Dug <br /> Longitude degrees minutes seconds rotary r ry ❑Jetted <br /> House Number,Street Name,City,and Zip Code <br /> +oof,,Well,Location or FireeNumber .- 'C Auger , oto <br /> 1555 rd Flex, 55364 DRILLING FLUID` WELL HYDROFRACTURED? 11 Yes to <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. bentonite From ft.To ft. <br /> Showing property lines, <br /> roa buildings; d direction. USE <br /> N � y` ti- � , omestic ❑Monitoring []Heating/Cooling <br /> ----__ --_--______.-- ! .r. _ - - ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> Community PWS ❑Irrigation ❑Remedial <br /> �+C! ❑Elevator ❑Dewatering ❑ <br /> w E �, 7 ) CASG MATERIAL u <br /> T Drive Shoe Yes '(Jo Dtk <br /> b❑'Steel ❑Threaded ❑Welded <br /> h Mile ❑ <br /> I APlastic <br /> CASING0 <br /> S <br /> Diameter Weight Specifications <br /> 10. <br /> I 1 Mile— I /'�...�'^' ___14,_in.to la ft. t 9 lbs./ft. __in.tot. <br /> PROPERTY OWNER'S NAME/COMPANY NAMF>f _,,,1--"` LY_ in.to ft. <br /> TiT-lbs./ft. - - _$ in.toft. <br /> Pat Wysocky <br /> , in.to ft. lbs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREE OPEN HOLE <br /> s as Make + �* From .�ft. To_ ft. <br /> Type stalanleMss� steel. Diam. t� <br /> Slot/Gauze IAA Length 4t + 40 <br /> Set between_An_ft.and 1 ft. FITTINGS 2114X241. w <br /> STATIC WATER LEVEL <br /> Measured from _ <br /> 60 ft.LI, elow ❑Above land surface Date measured 6..3,.08 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> _ 118 ft.after 1r5 hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> 1 itless/adapter manufacturer, _I.y yje..i. li odel <br /> ❑Casing Protection 102 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) j <br /> GROUTING INFORMATION <br /> Well grouted ?hes ❑No <br /> Grout materials (i Neat cement [ entonite ❑Concrete ❑Other <br /> From )To _ft. 3 ❑Yds. Lags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From, To110 ft. �_nu ❑Bags <br /> MATERIAL From It© To 28travelli ]fs. IL-tags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay yellow soft 0 <br /> is -2, feet �. direction ,.l =--'-s- 1e <br /> Well disinfected upon completion? I? 'es ❑No <br /> gray <br /> clay ft 18 90 PUMP j' f_ <br /> rfine sand Q� soft 90 128❑Not installed Date installed (.O" k( 0 8 <br /> ,r `�`--� i Manufacturer's name }7� <br /> Model Number HP -1"1, Volts C7G7 <br /> Length of drop pipe 8 / r ft. Capacity g.p.m. <br /> Type:[Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes [ lo <br /> '•_••04,7 ',' VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes [(Vo TN# <br /> WELL CONTRACTOR CERTIFICATION )11f <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 /> DISI Stodola Well Drilling Co., Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> ....AK:/-‘...r -/ .. / i"�!' 1 8R 7o8 <br /> Cer -d'•:"es: tative Si.nature ' i Certified Rep.No. Date <br /> LOCAL COPY 7 6 0 6 2 6 /borne ' <br /> Name of Driller Cheek <br /> IC 140-0020 HE-01205-11(Rev.3/07) <br />