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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 658611 <br /> Hennepin Minnesota Statutes Chapter 103/ <br /> Township Name Township No. I Range No. Section No. Fraction WELL DEPTH(completed) nDate Work Completed <br /> rono 1 117 123 7 SEANK, SE,/. 394 2-14-01 <br /> :635 Tnnj[jaVjeW T.n House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger X Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> /1�p roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> " Bentonite FROM ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> X Domestic ElCommuni PWS <br /> -- -a- - - -- ❑ Irrigation ty ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> WE ❑ Environ.Bore Hole <br /> El Dewatering ❑ <br /> i /Zrnaa CASING Drive Shoe? X Yes ❑ No HOLE DIAM. <br /> ,X Steel ❑ Threaded ❑ Welded <br /> 1 <br /> EJ Plastic ❑ <br /> s <br /> i ruin <br /> X CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 370 ft. 231 &Oft. $_in.to <br /> Hark Hoon in.to ft. lbs./t6 -1/4 to3_70t. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./f3 <br /> V,to a 9.dt. <br /> SCREEN OPEN HOLE J 'f <br /> Make from 370 .to 394 ft. <br /> Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 145 ft.X below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 360 ft. after hrs.pumping S 0 g.p.m. <br /> WELL HEAD COMPLETION <br /> L*itless adapter manufacturer fdhi t4RVA tlal Model <br /> ❑ Casing Protection X 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? Wes ❑ No <br /> HARDNESS OF FROM TO Grout Material ❑ Neat cement El Bentonite El Concrete ZHigh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL from 33 to 7 ft. 4 ❑ yds.$ bags <br /> from to ft. ❑ yds. ❑ bags <br /> sandy cM*dy brown Red 054 54 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> sandy clay blue med 54 135 60 feet north direction sewer type <br /> Well disinfected upon completion? X Yes ❑ No pipe <br /> pe <br /> silty sand gray oft f i e 135 2 UMP s� <br /> ❑ Not installed Date installed 2"19-01 <br /> sandy clay gray med 297 368 Manufacturer's name Myers <br /> p Model number HP 1 Volts 230 <br /> ShaleXrocx yellow hard 368 394 Length of drop pipe 180 ft. Capacity g.p.m. <br /> Type:Xl Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ] No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes X No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 /> t!t,L2L/ <br /> add47,R71p <br /> Licensee Business N L'.or Reg.N4. <br /> Authorized Representative Signature Da e <br /> Hob Stodola <br /> Name of Driller Date <br /> LOCAL COPY 658611 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />