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11 <br /> AWE!_;LCZCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 591096 <br /> H e n n e o i n Minnesota Statutes Chapter 103/ <br /> Township Name Township No. tange Na Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 08 153 • n 9-30-98 <br /> House Number,Street Name,City,and Zip,it e of Well Location .olF.iraN ber ( DRILLING METHOD <br /> 1090 Tonkawa Road 'Or MN. 45539 i El Cable Tool El Driven ❑ Dug <br /> ❑ Auger R1 Rotary [I Jetted <br /> Show exact location of well in section grid wilh"Xw•w*�.� .� °'Sl�etch map of will locaticIn N ❑ <br /> Showing pro erty lin <br /> ...-�- roads ad <br /> s DRILLING FLUID <br /> N Natural <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> } X Domestic <br /> [I Irrigation ❑ Community PWS ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> WE <br /> T f 7 Test Well <br /> F] Dewatering El-, r Uz Mne CASING Drive Shoe? ❑ Yes X No HOLE DIAM. <br /> ❑ Steel r] Threaded - ❑ Welded <br /> V Plastic Cl <br /> S <br /> 1 M,le <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to—15 ft. —i.9 lbs./ft. ; in.to3_0_ft. <br /> Lauer Homes _.— in.to ft. lbs./ft —�f`4rl�ft. <br /> Property owner's mailing address if different <br /> than well location address indicated above. -_.-_ in.to ft. __. lbs./ft. in.to ft. <br /> 509 N. Ferndale Road SCREEN_ OPEN HOLE <br /> Wayzata, MN. 55391 Make_. johnson___ from ft.to fL <br /> Typ Diarn 2 0 _ <br /> Slot/Gauze f 1707 _Length L 8• <br /> Set betweeny1 V-- ft.and ft. FITTING <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME fK❑ below ❑ above land surface Date measure—�B <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping Q na�.a_aa_A rr _gp.m. <br /> WELL HEAD COMPLETION <br /> Pitless adapter manufacturer ►_►L t e.__s e r Model <br /> Cl Casing Protection X❑ 12 in.above grade <br /> F7 At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> (tell grouted? XJ Ves EIN'Ve `..«._. <br /> GEOLOGICAL MATERIALS COLOR FROM TO Orbu(Material ❑ Neat ��iiiohite ❑ Concrete gh <br /> HARDNESS OF hH Solids Bentonite <br /> MATERIAL from o to ft. ❑ ❑ bas <br /> 3-0- 2•�- Y� 9 <br /> from_ to ft. ❑ yds. ❑ bags <br /> from _ to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction __type <br /> Well disinfected upon completion? i Yes ❑ No <br /> ay Sand Gray 60 1 30 PUMP <br /> ElNot installed D I installed 10-27-98 <br /> ,.later Manufacturers nanIT O4tEt�WNER' - Predator ST <br /> r Modelnumber ST20-20 HP2 VoltQ1j0 <br /> Length of drop pipe 8 4 ft. Capacity 2 0 —9 p.m. <br /> Pressure Tank Capacity a2 S 0 <br /> Type[] Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes X No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/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 STODOL.A WELL DRILLING CO. INC. <br /> Licensee Business Name Lic.or Reg.No. <br /> / ' t 27172 <br /> filAuthorized Reb'eser'tahv nature Date <br /> Chuck Moore 9-30-98 1 <br /> Date <br /> Name of Driller HE-01205-05(Rev.1195) <br /> LOCAL COPY 591096 <br />