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<br /> WELL�OCA110� MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO.
<br /> coU�tY Name WELL AND BORING RECORD�-�• • � �g O O O
<br /> Hennepin Minqesota Statutes Chapter 1031
<br /> Township Name Township No. Range No. Section No. Fraction � -�.�WELL DEPTH(completed) Date Work Completed
<br /> Orono 118 23 Zb ,, ,, ,, , 275 " 7-18-03
<br /> GPS �� DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds _ -
<br /> .. CaCleTool �.•� �,s ,{ Qnven � � I,J���Dug�
<br /> Longitude degrees minutes __ seconds __ - T+�- �� .,-;- �
<br /> - ��Auger � �iota�y ]Jettetl
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number 3w,�r-" . , �
<br /> 1 1 G) Sp r i ng Hi I l RU� �O�Ci n ��3�:} �FLUID )NELL HYDROFRACTURED? ,��Yes No
<br /> Shop exact location of well in section grid with"X". � � � .Sketch map�of well IOca�ion �. �''�`'..^r � � � � �
<br /> � r . FROM � ft.�TO_ ft.
<br /> � �� Showing properry lines. � " -- �� --- � .
<br /> . N . - � . . ,..� roads.and bu�ldings U r >�. � � .- � � r �
<br /> .� � � � �'� � � Monrtonng ... �Heatina�Cooling��� �
<br /> �.
<br /> -'-- --.---t `--. ' �'.. ::`' ., ; � '� r�[3omestic:. . ':� i�Environ Bare Hole I��4ndustry>Cofimercwi-
<br /> .�� ' � �?Nonc.ommunRy,F�S' � i[�igation � �Femedi� � �
<br /> - -- -- �`�� � � , ' �'Comrrlunity PWS _,DeHateri g•-,�: " i -_„ _�_- —
<br /> ,. ,. ' - . - .. . � .CA�{IVG. _ . � . � -HOL��IAM
<br /> W . .E T . .. . - � bnve Shoe� �Yes ' ..,.,ge �;
<br /> � ,_ _-- -- -�-� � t � � tiued
<br /> e - �' i "siio- >�J.
<br /> , ,
<br /> .. i � `� r y,
<br /> i
<br /> l
<br /> ,,,_ Ste Threatled
<br /> :
<br /> . �_ �
<br /> '/fzMiYe � ._ S \i : . ...---'-
<br /> - - --��_. 1 . - -�:i3�{,j. � "`.CASING-DIAMETER.,.� � �-� -�W�IGHT .�.. . � =.- .. .
<br /> � � � � - `"�' �� ��'* ft. 11 IbsJft. in.to .7lJft.
<br /> S`
<br /> ', : '" � . �-----�in.to ,
<br /> � ,. . f _ .--.�-1 Mite�—�-{ . . . . / �� . .. �-- ey )- ;
<br /> ' -. ��I '�. .�� in.to ft. ------.-----Ibs./ft. _4_. in.toG 3Yft. _
<br /> _-" �:PRO�ER7YOWNER'$.NAMElCDMPANYNAME in.to ft. Ibs./ft. __/1.4T.toL�7�ft. ��
<br /> ::.�.�elman SCREEN OPEN HOLE
<br /> �.�-roperty owners mailing address if different than well locatior addre;s indicated above. Make FROM �+�'* ft. TO Z 7 5 ft.
<br /> '�._..��-J'tn �S'"{��1netOnka �lnd Type —_.__Diam.— __ _.. -
<br /> ? , '��Rnetonka, �N 55391 SIoUGauze _____ Length __
<br /> Set between_ ft.and it. FITTINGS
<br /> �.�„''; . STATIC WATER LEVEL
<br /> - - � 10� _ft�_i below ��above land surface Date measured__.7�8-03
<br /> * . �W�LL�OV��` RS N7�ME;COMPANY NAME PUMPING LEVEL(below land surface)
<br /> �` � ' 2 3`} ft.after _3 .hrs.pumping__�_Q_ g.p.m.
<br /> " ��- �"` �.��,,, � ' � �WELL HEAD COMPLETION � � 1
<br /> �' �.��Well.pvineT's maiUhg,addrESs if dilfAtent,�han>property ov�ners addcgs§indicated above. -. � '�pitless adapter manufacturer�..�-1` �.�t�'_''��.�T rl.�'Model . �
<br /> �,� � � 'Casing Protection_ �12 in.above grade
<br /> ,;� - ! 'At-grade(Environmental Wells and Boring ONLY) -
<br /> i: � , - .�;;` �� � GROUTING INFORMATION � � - � -
<br /> � "� ` Well grouted -�-�Yes ��"No .
<br />_.,��.,, '� �.�� �y ,` ,��_i '��. . .;'�. � � Grout matenal __. eat ce nt ��;Bentonite ,�Concrete iJ High Solids Bentonite
<br /> ,-::_�- . .:N me �
<br /> -:. .� ' �' � .�=, ..' - q
<br /> �, . .. .: . ;� ,. .-.''. . `:. from- }Q to _.70 ft. --3— r-�Yds. =��bags
<br /> c+� , .�,_ . ., ... ,..
<br /> w ;. . _:' ,. ���� .. , _., Y t: _- . . ; � " .._, . from 3L_ to Z 3�f__..ft. n8 ur8l�_��1��ags z
<br /> �, .. ... _ -�. :, . .. ,, .
<br /> " HARDNEgS dF ;
<br /> ... � .�. QEO�OGICA��MAFERIALS�-� = �.�COLOR ���; .:� F.RQM--. Tp . .���� from to_. __.ft. i I yds �=_j bags
<br /> . ;. �. . . ..,...�. . _.- . ..MA7ER(AL ��.. . a, . .
<br /> „
<br /> � , . '� �NEAR.�SY KNOWN SOURCE OF CONTAMINATION
<br /> _. . r :. . . „__
<br /> _., � , . . . -_
<br /> ;, .
<br /> ` :
<br /> � �. :' ,. '"' teet � ti..- direct' J_ . f� �; :. �� �
<br /> C�3� ``'�" tsi�� ��' —, . ` r- ) wn _ _ e
<br /> ����. Well dismfected upon campletion,- ,'-_,'��Yes .=�,No
<br /> } t PUMP
<br /> C18�:�, � '^�"'.j ���0. ' ;�� .. 4 �in.:� .�� -:� � .. �I � i\� .. 1.
<br /> � Not installgd Date in3t2lled �'
<br /> � CLA���'��'�� ' ;l#"':'ttj a'��.L�:.T! ;�. 1�� " '��'�� Manutactuier'snema t
<br /> �� . .�,.a..� ; �... ., . ... . : ,Modaln - ,��. ., . .., : . , . _ 1.-L ,
<br /> ,.--
<br /> -�. [ :. . :;.� �. � umber__ ;.� •.' ..-� �^ ��� HP ' ���--.. Volts_. ..� ^.- �J �.
<br /> �
<br /> limeste�ne �"ziT�. i,�7��- : `��� �7� Eengthofdroppipe� '� .� _fit; Capaciry g.p.m.
<br /> � '.: .... . � �-.�. �,. � . :'. . '.. ;ype y'1 Submersibfe��.`�l LS_Yurbine ��Reciprocating � ,Jef-�^ �. ��. . � .
<br /> ,. .._ . �.. , �,. -. .,�. :.. '. `�:.�ABANDONEd'WELLS �� .� ..- ��� .. � �. �.
<br /> � �_ ,� ' ".Dpes.property.have any not In use artd nOt sealgd WeA(s)._ ' Yes'.<�No . �
<br /> � � � ����,�.VARtANCE,
<br /> . . , .. . .., ,: . , , .,..� ,_�:
<br /> - � � ` � � �� � �� ���� �� Was a varl2nce grante�i from the.MDH for ttiis v�ll? � Yes No TN#_.? � �^� ��. . ^-
<br />:;,, . ��� . �:`�:. `� . ..- �-- � . ,� . ��.�'WELL CONTRACTOR CF.RTIFICAT.ION ���� � `�-..:. � -- i•.:.
<br /> "� � � � � � � -� ��This weJl.was dnNed under my:supeiv�,sion�and in accordance with Minnesota Rulss,Chapfer 4725. -' �
<br />"'" ' . � � �, � - - � �"-Fhe mformation contained m lhis report is lrue to the kest o(my knowledge. ��� - --
<br />.�a.� - . � ... . . . . . � . . . .
<br />;„;� '� � � Use a second sheet,if needed � � � �� � � . � ,,
<br /> ���� REMARKS,ELEVATION,SOURCEOFDATA,eta ��j'1 �tQdOi�j Well Dri11.i�Co�. .�.si�_�___2_Z 72
<br />�' ---
<br />�.,. � Licensee Business Name _ Lic. r Reg.No.
<br />�' _/ ,,
<br />-,- . . - � � --- ------..__ ._. ._____�_ _ .. _ .- -- -.
<br /> ut ¢e epresentative Signature` Date
<br /> Chuck Moeoee 7-18-03
<br /> - — --- --__ - -- - - --- -__ -- - �
<br /> LOCAL COPY ? � Name olDriller oate ,
<br /> �� `'< °� � �0
<br /> HE-01205-OB(Rev.5/02) -A
<br /> IC 140-0020
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