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i <br /> WEL LOCATI(,N MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> ` WELL AND BORING RECORD <br /> County Name <br /> 573596Hennepin p Minnesota Statutes Chapter 1031 <br /> Township Name Township No. I Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> )rono 117 2 Ula 277 ` <br /> House N,mber,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 257t) Thoroughbred Lane ©rono,MN. ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger X1 Rotary ❑Jetted <br /> Show exact location of well in section grid with"X". 553-56 Sketch map of well location. ❑ _ <br /> Showing pr erty lines, <br /> road uildings. DRILLING FLUID <br /> N 4, Bentonite <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> 41 Domestic ❑ Community PWS <br /> El Irrigation y ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> WE ❑ Test Well <br /> El Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> ❑ Steel 11 Threaded El Welded <br /> X Plastic ❑ <br /> s <br /> �- 1 Mile <br /> X e CAST,!G DIAMETER WEIG§ <br /> I- <br /> PROPERTY OWNER'S NAME . 26DR. 21 7 7�8 30 <br /> into ft. lbs./ft. n. o. <br /> Tony , a � �: Company6� /1 <br /> in.to ft. lbs./ft. id to �. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> 411,10, Berkshire Lune SCREEN OPEN HOLE <br /> Plymouth, Mn.5 5 Q 4 b Make from ft <br /> JQ nson .to ft. <br /> Type _a l nl s+c" st _ 1 Diam. 1 <br /> Slot/Gauze ' Length 11 1 + 4 1' <br /> _ _ <br /> Set between ft.and L � FITTINGS: 1 <br /> STATIC WATER LEVEL I <br /> WELL OWNER'S NAME 1 L�' ft. below ❑ aboLeland„Wace Date measured2-23-96 <br /> PUMPING LEVEL(below land surface)^ <br /> Well owner's mailing address if different than property owner's address indicated above. 264 ft. after hrs.pumping 50 g.p.m. <br /> WELL HEAD COMPLETION <br /> witless adapter manufacturer W b 1 t enw'i t'>r r Model <br /> ❑ Casing Protection YC 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? CXYes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO oto �1 ft. 1 g ❑ yds. bags <br /> from <br /> C1 y ye 1 l t} IS Ci ' In <br /> ' from to ft. 11 yds. Ll bags <br /> from to ft. ❑ yds. [I bags <br /> lay Gre J C 3�- 1 ?�, IINEARE T KNOWN SOURCE OF CONTTq�p�IN TIO-Nye t fid <br /> l feet 9cl -5 direction �`�" �' type <br /> Sand, Gravel Tan S 7C 957, Well disinfected upon completion? LAIes I-] No' <br /> PUMP �14�` <br /> Clay--Gravel Grey S J` 1 1)- s❑ Not Curers Datgi stalled L7 <br /> Manufacturer's name �� e <br /> Model number HP .J Volts 230 <br /> Clay-Gravel Brown M 15-5 : 20C, 'Length of drop pipe 147 ft. Ci <br /> apacity g g.p.m. <br /> Pressure Tank Capacity Xtrol <br /> Ca y, Gravel Bou :1 e r S Mixed M--11 2 0( 1 2 2 OTtpe: 19 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Clay-Gravel Yellow M 220 ' 239 1 Does property have any not in use and not sealed well(s)? ❑ Yes LQVo <br /> 't C VARIANCE <br /> Clay Grey M 235 ' �.v J 'Was a variance granted from the MDH for this well? ❑ Yes EDQJo <br /> I <br /> .-7 1 WELL CONTRACTOR CERTIFICATION <br /> Gravel YellM t6' � / <br /> Use a second sheet,it needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> DON ISTODULA WELL DRILLING CO. , INC. <br /> Licensee Business Name Lic.or Reg.No. 27172 <br /> 2-23-96 <br /> Authorized Representative Signature Date <br /> FredLeiby 2-23-96 <br /> Nameo/Driller Date <br /> LOCAL COPY � 573596 HE-01205-05(Rev.1/95) <br />