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! - WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. � �o��tYName WELL AND BORING RECORD 6 5 5 010 Hennepin Minnesota Statutes Chapter f03/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed u Ol'Oi1� �.1.7 �� Q�i �i. �i. �i. n. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 4 5 5 Sus s ex Lane E}r011� 5 5 3 5 ❑ Cable 7001 ❑ Driven i I Dug � Cl Auger �Rotary f� Jetted �. Show exad location of well in section grid with"X' Ske�dh map of well location. f� __.____ `: ��/Showing property lines, �- �� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �M110 N _ �\ � � � � - ,� _._ _ �a t e r FROM n.�o h -,- -,- -,-- -,- ,.. USE ❑ Monitoring ❑ Heating/Cooling � i i i � �Domestic ❑ Community PWS ❑ Indust /Commercial _i_ _�_ _�_ _i_ ❑ Irrigation ry i i i i ❑ Noncommunity PWS ❑ qemedial w i l e T _ ❑ Environ.Bore Hole ❑ Dewatering ❑ _ -i- -,- -r- r ��ZIM1e CASING Drive Shoe? � Yes C�No HOLE DIAM. _i � i �_ I ,� ❑ Steel ❑ Threaded � `C7 Welded _ ___ _ _ _ 1 �'Plastic ❑ s � �1Mile� f CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �in.to��ft. �� Ibs./ft. � � in.to tt. 2on Eiden C�• in.to_ fl. IbsJfl. m to��_��.pp ft. z �' Property owner's mailing address if different than well location address indicated above. __in.to_____R. __,_____. Ibs./ft. �in.to' ft. � 4100 A�rkshi re LCine SCREE�IO On OPEN HOLE Plymouth, 1KNN 554�6 Make •� � _ from ft.to ft. Type $�$�f 1e.9$ SC�el _Diam. _ SIoUGauze ��,�n Length �� ♦ 4 f Setbetween �_J� ft.and_�_�_tt. FITTINGS: '�rv'�/1'» e.:�b�y Y STATIC WATER LEVEL WE�L OWNER'S NAME ��__ ft. 9.below ❑ above land surface Date measured 6_� �� PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. t �f'f ry, after �f hrs.pumping__��__g.p.m. --Z G T- WELL HEAD COMPLETION __y, �Pitless adapter manufacturer w��..��_ Model ._ .._ ❑ Casing Protection__ _ �.12 in.above grade ❑ At-grade(Environmental Wells and Bonngs ONLY) GROUTING INFOFMATION Well grouted? �'Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite r7 Concrete �High Solids Bentonite MATERIAL from�to ��ft. 2_�S_ _ ❑ yds.f�'bags from to ft. � d�.� bags --�$— —�� A8 t IIIB� �i from to ft. yds. bags NEAREST KNOWN SOURCE OF CONTAMINATION �j feet __ ��_.►L direction �_type Well disinfected upon completion? �Yes ❑ No � 't PUMP ❑ Not installed Date installed_�_��,_�� Manutacturer's name Model number HP � Volts__._¢�� �•! LJV �` Length of drop pipe�7 _ ft. Capaciry ._g.p.m. _ _ Type:�Submersible ❑ LS.Turbine Cl Reciprocating ❑ Jet ❑ _____ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �No VARIANCE jWas a variance granted from the MDH for ihis well? 17 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. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. ' Don L�edola_ Well Dr�,lling Co.; In�. 2 172 ; Licens Business Name - L� r Reg.No. � �' � 1��1'�(?� ` u o e R rese iv ignature Date � Chuck Moore 9—ZI-0� Name ol Driller. Date t LOCAL COPY 6 5 5 010 HE-01205-07(Rev.2l99)