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Well Construction Report Drinking Water and Groundwater-DG/5 Form 3300-077A <br /> WISCONSIN UNIQUE WELL NUMBER ABZ096 Department of Natural Resources,Box 7921 <br /> Madison WI 53707 <br /> Property JAMES WILTROUT Phone# <br /> Owner 1.Well Location Fire#(if avail.) <br /> Mailing 9162 SPANGBERG ROAD Town of DANIELS 9162 <br /> Address Street Address or Road Name and Number <br /> City SIREN State WI Zip Code 54872 SPANGBERG ROAD <br /> County Co.Permit# Notification# Completed Subdivision Name Lot# Block# <br /> Burnett 9654028801 10-14-2024 <br /> Well Constructor(Business Name) Lic.# Facility ID#(Public Wells) Latitude/Longitude in Decimal Degree(DD) Method Code <br /> D M B DRILLING CO INC 6749 45.7997 °N -92.4557 °W SCRO02 <br /> Well Plan Approval# SW SE Section Township Range <br /> or Govt Lot# 3 38 N 17 W <br /> Address W8760 CTY HWY J <br /> SHELL LAKE WI 54871 Approval Date(mm-dd-yyyy) 2.Well Type New Well <br /> of previous unique well# constructed in <br /> Hicap Permanent Well# Common Well# Specific Capacity Reason for replaced or reconstructed well? <br /> 1.5 <br /> 3.Well serves 1#of HOME Hicap Well? No <br /> Private,potable Hicap Property? No <br /> Heat Exchange_#of drillholes Hicap Potable? No Construction Type Drilled <br /> 4.Potential Contamination Sources-ON REVERSE SIDE <br /> 5.Drillhole Dimensions and Construction Method 8.Geology <br /> Dia.(in.) From(ft.) To(ft.) Upper Enlarged Lower Open Geology 8.Geology Type, From(ft.) To(ft.) <br /> Drillhole Bedrock Codes .Caving/Noncaving,Color, <br /> 6 Surface 140 Hardness,etc... <br /> No Rotary-Mud Circulation.............. No _ <br /> T S Y T-TAN/BROWN S-SOFT/LOOSE Surface 140 <br /> Yes Rotary-Air................................ NQ Y-SAND &GRAVEL <br /> No Rotary-Air&Foam.................... No <br /> Yes Drill-Through Casing Hammer <br /> No Reverse Rotary <br /> No Cable-tool Bit_in.dia... No <br /> No Dual Rotary............................... No <br /> No Temp.Outer Casing_in.dia <br /> N Removed?_depth ft.(If NO <br /> explain on back side) <br /> 6.Casing,Liner,Screen 9.Static Water Level 11.Well Is <br /> Dia.(in.),Material,Weight,Specification - From(ft.) To(ft.) 100 ft.below ground surface 20 in.above grade <br /> Manufacturer&Method of Assembly 10.Pump Test Developed? Yes <br /> 6 WHEATLAND STEEL ASTM A53 18.97.280 Surface 137 Pumping level 110 ft.below surface Disinfected? Yes <br /> WALL WELDED JOINTS <br /> Dia.(in.)'Screen type,material&slot size From(ft.) To(ft.) Pumping at 15 GP M for 1 Hrs. Capped? Yes <br /> 4 TELESCOPE STAINLESS STEEL 12 SLOT 136 140 Pumping Method? Airlift <br /> 7.Grout or Other Sealing Material 12.Notified Owner of need to fill&seal? No <br /> Method MOUNDED <br /> Kind of Sealing Material From(ft.)' To(ft.); #Sacks Cement <br /> GRANULAR BENTONITE Surface 3 S Filled&Sealed Well(s)as needed? No <br /> 13.Constructor/Supervisory Driller Lic# Date Signed <br /> DMB 6242 10-14-2024 <br /> Drill Rig Operator Lic or Reg# Date Signed <br /> SMS 9029 10-14-2024 <br /> WISCONSIN UNIQUE WELL NUMBER ABZ096 <br />