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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o��Y Name WELL AND B�RING RECORD 6 5 5 9 7 6 Hennepin Minnesota Statutes Chapter 103! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono l ll 23 17 1�E i,NEi,SE �i. L07 n 8/3/Ol House Numbec Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven [] Dug 12 � ❑ Auger � Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ _______ Showing property lines, roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES eG'l NO N '� i i i Water FROM ft.ta tt. __ _i_ _i_ _i_ ��_��,�.�.......+�+.�� USE ❑ Monitoring ❑ Heating/Cooling i i � i --•..» � �'�"L"�"��-�--��^.. Domestic ❑ Communit PWS _i_ _�_ _�._ _i_ ,,,.1e..�...,..�„+��„�„�.ns..�°r � Irrigation Y ❑ Indusiry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w i i i e ^ �y ❑ Erniron.Bore Hole ❑ Dewatering ❑ / ]�[r -i- -i- -i- -; I ` �-�-i"""� CASING Drive Shoe? ❑ Yes p No HOLE DIAM. 4zM�ie i i _i _ _i_ ❑ Steel ❑ Threaded f� Welded -i - i- i i 1 p Plastic � �],(le S -�J.; �—,M�a� j ' CASING DIAMETER WEIGHT 7 PROPERTY OWNER'S NAME 4 in.to �.�Q ft. Ibs./tt. �in.tdi5 ft. �� . i.ro ft. __ Ibs./ft. �In.ta1.Q�ft. Property owner's mailing address if different than well location address indicated above. ___._ __—.in.to____ft. Ibslft. _in.to ft. . P•O.BO� b33 SCREEN OPEN HOLE - '�� � Make i�___ from_ ft.to ft. ` Delano, :�+1 55328 T„PQ "�' �(', _ Diam. SIoVGauze__�_.__. _ Length_T_� - Set between _�8�_ft.and�3__fl. FITTINGS: STATIC WATE:R LEVEL WELL OWNER'S NAME �� tt. i7 below ❑ above land surface Date measured A1 Hirseh Builders PUMPING LEVEI(below land surface) �C Well owner's mailing address if different than propeAy owner's address indicated above. _ ft. after___ hrs.pumping. YS g.p.m. �. S$A!� WELL HEAD COMPLETION � Pitlessadaptermanufacturer_. MflAf3 __ Model �j�t ____ Casing Pro[ection _______,_____ L7 12 in.above grade fl At-grade(Environmental Wells and Borings ONLY) .�4 GROUTING INFORMATION Well grouted? [}Yes ❑ No HARDNESS OF Grout Ma[erial �� Neat cement Bentoni�e ❑ Concrete ❑ High Solids Bentonite GEOLOGICAL MATERIA�S COLOR MATERIAL FROM TO from��o�ft. � ❑ yds. ❑ bags - - from _ to __ft. ❑ yds. � bags '� Cl$� YelloM � is from . ._to_ fl. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION �`� , . � . ., L'la� T$II ig 23 .--_-�-. feet _direction __._ - ��type Well disinfected upon completion? ��Yes ❑ No CZSy CaY8 23 3� PUMP ❑ Not installed Date installed ��^ �,F—/j� —_�o�—a—� � Gravel � Sand Mixed �7 iQ7 nnanutacturers name ��:�/: :�,� _ Model number_ _______ � HP H _7 _ Volts �nZ . Length of drop pipe �,[_y_ __ ft. Capacity �� g.p.m. t.:.�v �� Type: Submersible ❑ LS.Turbine ❑ Reciprocating C7 Jet ❑ _ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Ves No VARIANCE Was a variance granted from the MDH for this wd? ❑ Yes �No TN# WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed 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. REMARKS,ELEVATION,SOURCE OF DATA,etc. $tevens DrillinQ_.� Ehq_ S�rvi��a___��,ggt� Licensee Business Name Lic.or Reg.No. } _/ ---=---.._/C� - L.�., ,I � . . �. . ____-=-. __ __ -- ' ALthorize Representative Signature Date • �A --L�-�f/�) ' ame o rr e� • •Dal� �� 655976 � LOCAL COPY ' HE-01205-07(Rev.2/99)