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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/NI�G NO. ELL CountyName WELL AND BORING RECORD �, � 3� � g Hennepin Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 11$N 23W 29 ,, �,, SF 162 tt. Auguat 1, 20t?7 � GPS DRILLING METHOD - ; LOCATION: Latitude degrees minutes seconds �i LongiWde degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug ❑Auger �,I Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � 3560 6th Ave A, I+OT1g L8� DRILLWG FLUID WELL HYDROFRACTURED? ❑Yes �,No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �8t�r From ft.To ft. Showing property lines, N roads,b�di��d#ection. USE �Domestic ��Monitoring ❑Heating/Cooling �.; � � � � �...�,,•� – - �; __:____;___ ___L____:__ �]Noncommunity PWS I ]Environ.Bore Hole ❑Industry/Commercial �`� �� ❑Community PWS �_�Irrigation ❑Remedial I I I I •; ;� . _ .: --'--- --+-----`-----;– ��'�`� �l Elevator �_J Dewatering ❑ �1 W , , � � E � CASING MATERIAL � , , ; ; T 1 Drive Shoe? ❑Yes �]No HOLE DIAM. --�--- --�----�----.– � �� , , , , 'h Mile elded ❑Steel ❑Threaded �]W , , , . � �]Plastic � �211� --;-- --T-----�-- --�- CASING � g � Diameter Weight Specifications ��Miie—� � � �� in.to 1 S 7 ft, Ibs./ft. �. in.lo�ratl_ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to n. ibs.in. 6; in.toiv2 ft. T@X SIld �OI111$ Ostvig in.to ft. Ibs./ft. _ in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 3560 6th Ave H Make .T8�C0 From ft. To ft. � uaa.a� � S5356 Type ___�� __Diam. * g SIoUGauze 1� Length t S Set between �S7__ft.and 162 ft. FITTINGS A j3$��Qr STATIC WATER LEVEL r�� Measured from o �3 ft.j[;Below ❑Above land surface Date measured_q 1 O7�'� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) T�7C �1� �flfl� �s�ig ft.after hrs.pumping SQ g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION H �Pitless/adapter manufacturer �a88 Model � ❑Casing Protection �12 in.above grade �At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted �Yes ❑No . Grout materials ❑Neat cement�]Bentonite ❑Concrete �]Other From.1Q—To�.�ft _�__ ❑Yds. �]Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_._To ft. _ �I Yds. ❑Bags MATERIAL From To fl. [1 Yds. r;�Bags NEAREST KNOWN SOURCE OF CONTAMINATIONdvel SOt fLO� S�V�Z C�y yell� � J� ___feet __direction . type Well disinfected upon completion? �Yes ❑No �� gray 3� 90 PUMP (� n [;Not installed Date installed G � ' � �� • �� 8�� =�d 9� 124 Manufacturer's name � � 1 y t �.��'t- ��C.�� ! . + j 3 Model Number HP 1 Volts elay gray 120 140 4 �a Length of drop pipe `��.' 1 ft. Capaciry ` � g.p.m g� gray iy� 262 Type:�Submersible ��LS.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes �No VARIANCE Was a variance granted from the MDH for this well? ❑Yes �No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Stevens Dzilling S Bnv. Svc, Inc. 2255 Licensee Business Name � Lic.or Reg.No. !...� . , ��'_ ,��--- SbbS� 8/8/07 Certified Representative Signatu Certified Rep.No. Date LOCALCOPY 7 �3539 ��Y'�{'� ��r ��U Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6) '�,