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... : '''''',,!k' <br /> ,!#' [it - ; a.',''T ar. to i "4 at°' �t <br /> fir- r .- . rt1.4.4.--;,".2...u: au :ay.�$:, i s° �'.�'-`-,` t,. , r <br /> MINNESOTA UNIQUE WELL NO. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> County Name WELL AND BORING RECORD {-. <br /> 615. 83 <br /> Hennepin Minnesota Statutes Chapter 1031 ����- <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) ft Date Work Completed <br /> Orono 118 23 31 172 9-24-98 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> t ® 0 Cable Tool 0 Driven ❑ Dug <br /> 4440 $t e r t�? Rd ©ron© 55359 ❑ Auger WRotary 0 Jetted 4A q <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ ,t r' <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ICAO <br /> )�� (16. water FROM ft.to ft. <br /> i// USE 0 Monitoring ❑ Heating/Cooling <br /> Domestic ❑ CommunityPWS <br /> 0 Irrigation 0 Industry/Commercial <br /> J i ❑ Noncommunity PWS 0 Remedial <br /> w I s C:D ❑ Test Well 0 Dewatering 0 <br /> r <br /> 1 CASING Drive Shoe? 0 Yes 0 No HOLE DIAM. <br /> I 1/2M40 <br /> ❑ Steel 0 Threaded 0 Welded <br /> ____ l �astic Els <br /> 1 Mlle ) 611:› <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �YjLICJ "'^ 4 in.to 16 3,. sd r-21 Ibs./ft. $ 740 f .0 <br /> Cathy Smie ja �`ll.�-- n.to ft. lbs./,. V( n.to�f <br /> Property owner's mailing address if different than well location address indicated above. in.to ,. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make Johnson from ft.to ft. <br /> Type .�+Sa6ainle` — ! Diam. _ *!M <br /> Slot/Gauze .010 01o Length ( + <br /> Set between 172 <br /> ft.and ,. FITTINGS: <br /> STATIC WATER LEVEL ,,��..!! <br /> WELL OWNER'S NAME 100 ft./6elow 0 above land surface Date measured 9--24-98 <br /> PUMPING LEVEL(below land surface) <br /> Welt owner's mailing address if different than property owner s address indicated above. 160 ft. after 1 hrs.pumping 2 2 g.p.m. <br /> WELL HEAD COMPLETION <br /> y( <br /> i Pitless adapter manufacturer whi tewa t r Model <br /> Casing Protection j'12 in.above grade <br /> 0 At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? L Yes 0 No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ ConcretefHi9h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from 0 to ft. 5 0 yds. "'bags <br /> fromto ,. 0 yds. ❑ bags <br /> Clay ;yellow soft 0 27 34 nab <br /> from <br /> r NEAREST KNOWN SOURCE OF CONTAMINATION (/�� <br /> Clay ,r B o i t 2 7 5 O ft. <br /> u feet 714 direction "�• /�❑ yds. ❑ bags <br /> type <br /> Well disinfected upon completion? Yes 0 No 51G�eg <br /> 9 <br /> Sand/ ;ravel tan soft 85 172 PUMP n A <br /> 0 Not installed Date installed "2 5-98 <br /> Manufacturer's name Homeowners pump, pipe, wire <br /> Model number HP 1/2 Volts <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type: f' Submersible 0 L.S.Turbine 0 Reciprocating 0 Jet 0 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes 46o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes $No <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 /> The information contained in this report is true to the best of my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> ECE QED <br /> Don Stodola Well Drilling Co., Inc. 27172 <br /> MAR 01 1999 Liic-nnse•Business .me Lic.or Reg.No. <br /> GiiY U1— /" _ _, 11-12-98 <br /> Uuf'JN° - Authorized Re•e- '"e ignature Date <br /> Fred Leiby 9-24-98 <br /> Name of Driller Date <br /> LOCAL COPY <br /> 615583 HE-01205-06(Rev.9/97) <br />