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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL- RECORD 530230 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Ran a No. Secti No. Fr do WELL DEPTH(completed) Date Work C I <br /> Orono 118N h 0 Sf k NW 196 Y�3y s/93 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> 425 Turnham Road ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> water <br /> t i I USE Domestic ❑ Monitoring El Heating/Cooling <br /> ❑ Industry/Commercial <br /> W i :X 1 E ❑ Irrigation ❑ Public <br /> El Test Well ❑ Dewatering El Remedial <br /> I � ' <br /> CASING Drive Shoe? ❑ Yes <br /> xl No HOLE DIAM. <br /> --�- - —r- I ❑ Steel ❑ Threaded ❑ Welded <br /> i � 1 <br /> Ix Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 191 ft. lbs./ft. �in.to 196 ft. <br /> William Stempel in.to ft. lbs./ft. in.to ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN��� co OPEN HOLE <br /> 425 Turnham Road Make may""' � from ft.to ft. <br /> Maple Plain, iA 55359 Type �8 s <br /> Slot/Gauzelot LLength <br /> Set between --------BI-ft.and 196 ft. FITTINGS: <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 127 ft.,X below Elabove land surface Date measured <br /> rt p PUMPING LEVEL(below land surface) <br /> 0 <br /> Clay brown 3$ ft. after hrs.pumping 75+ g.p.m. <br /> WELL HEAD COMPLETION u <br /> Clay gray 38 101 X Pitlessadaptermanufacturer Mass Model 4J1 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> Clay & gravel gray 101 129 GROUTING INFORMATION <br /> Well grouted? X Yes ❑ No <br /> Sand brown 129 152 Grout Material EX Neat cement ❑ Bentonite <br /> from to 30 ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> Gravel mixed 152 196 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? IT,Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed <br /> Manufacturer's name Goulds <br /> Model number HP 3/4 Volts 230 <br /> Length of drop pipe 140 ft. Capacity 10 — <br /> 9-p.m-Pressure Tank Capacity_ 33 gal- <br /> Type: X Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? a Yes ❑ No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed Stevens Well Drilling Co. Inc. 86654 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> 10/28/93 <br /> Authorized Representative Signature Date <br /> Paul Swearingen 10/28/93 <br /> Name of Driller Date <br /> LOCAL COPY 15302301 HE-01205-04(Rev.5/92) <br />