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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 660595 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 7 216 n 8-22-01 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool q Driven ❑ Dug <br /> 1355 Vine Place Orono 55364 ❑ Auger /�6 Rotary ❑ Jetted <br /> Show exact location of well in section grid with'X". JSketch map of well location. E)Showing property lines, <br /> \ roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES 11XNO <br /> N water <br /> FROM ft.to ft. <br /> f USE ❑ Monitoring ❑ Heating/Cooling <br /> ff X Domestic ❑ Community PWS ❑ Industry/Commercial <br /> _ _ _ _i_ o ! ❑ Irrigation <br /> i i i i tf��Y- J ❑ Noncommunity PWS El Remedial <br /> w E T ❑ Environ.Bore Hole <br /> "`",., '� El Dewatering ❑ _— <br /> Vzmae CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> Steel ❑ Threaded ❑ Welded <br /> 1 Plastic ❑ <br /> s <br /> 1 _`,` <br /> CASIN DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME in.1.208 ft. 2.05b /ft. in.to 3Q <br /> Daniel Ventres in.to ft. Ibs./it. in.to_M6 <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. _in.to ft. <br /> same as above SCREEN Johnson OPEN HOLE <br /> Make from 'to-ft. <br /> Type �'8 $ steel Diam. J. <br /> L t <br /> SloVGauze •010 Length 9 t ♦ 4 <br /> Set between 20_ft.and__2 1_6 _ft. RTTINGS:2*x30M w/-k <br /> STATIC WATER LEVEL / <br /> WELL OWNER'S NAME 40 ft.)fiJ below ❑ above land surface Date measured 8-22---01 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 7n7 ft. after 2 hrs.pumping ?� g.p.m. <br /> LL HEAD COMPLETION Whitewater <br /> Pitless adapter manufacturer ,M,{odel <br /> El Casing Protection /0 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? X Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ' High Solids Bentonite <br /> MATERIAL from__to 30 ft. 2* ❑ ydsX bags <br /> from 30 <br /> to 208._-tt. natural rytsI p bags <br /> Clap rown soft 0 60 from ft. yds.D bags <br /> NEyAJOWN SOURCE OF C�[[FA�pyJl> CT / j <br /> sand/gravel rows medium 60 80 U feet CC�� direction- bpe <br /> Well disinfected upon completion?� Yes ❑ No <br /> sand (fine) Eray soft 80 160 PUMP <br /> El Not installed Date installed 8-27-01 <br /> clay ray soft 160 200 Manufacturer's name <br /> L <br /> ! Model number i HP hp Volts 230 <br /> sand ray soft 200 216 Length of drop pipe $$ ft. Capacity g.p.m. <br /> Type: Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑ <br /> AB NDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes XNo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes tX <br /> No TNS <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 /> DonStod;la Well Drillin o. Inc 27172 <br /> Z4ensee Bu 'ess N e Lic.or Reg.No. <br /> 9-28-01 <br /> Authorized Represrentative Signature Date <br /> Chock Moore 8-22-01 <br /> Name of Date <br /> LOCAL COPY � 660595 /DillHE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />