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MINNESOTA UNIQUE WELL NO. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> County Name WELL RECORD5 3© 2 <br /> Hennepin Minnesota Statutes Chapter 1031 8 <br /> Township Name Township No. • Range No. Sectjon No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> Maple Plain 118N 24W 25 SW''SE''MW 137 5110/94 <br /> Numerical Street Address and City of ell Iron or Fir Number DRILLING METHOD <br /> iiiiilii lliXln" 4545 cv7 Pc( ❑0 Auger Cable Tool ,�0 Driven <br /> Rotary ❑ Dug ed <br /> Show exact location of well in section grid with"X". Sketch map of well location. 0 <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> --ir- -1-- - Bentinite <br /> I i .USE 0 Heating/Cooling <br /> _ X Domestic ❑ Monitoring <br /> W i E ❑ Irrigation 0 Public ❑ Industry/Commercial <br /> T 0 Test Well 0 Dewatering ❑ Remedial <br /> I . <br /> I'"' CASING Drive Shoe? 0 Yes X No HOLE DIAM. <br /> --1- - - ---r- 1 0 Steel 0 Threaded 0 Welded <br /> X Plastic <br /> H----1.1,,-----, <br /> i /X glue <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 130 ft. lbs./ft. 81/4 in.to 137t. <br /> Jeff Brol 1 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 -T_ayeG OPEN HOLE <br /> 1%5County Road 6 Make PVC from ft.to ft. <br /> Maple Plain, MN 55359 Type Diam._3. <br /> Slot/Gauze 18 Length 7 <br /> Set between 1 30 ft.and 137 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TOft. below 0 above land surface Date measured 5/10/94 <br /> MATERIAL 102 <br /> PUMPING LEVEL(below land surface) <br /> Clay yettow 0 30 ft. after hrs.pumping 40-50 g.p.m. <br /> WELL HEAD COMPLETION <br /> Gravel yellow 30 48 0 Pitlessadaptermanufacturer Model <br /> 0 Casing Protection 0 12 in.above grade <br /> Clay/ gravel Gray 48 94 GROUTING INFORMATION <br /> Well grouted? X] Yes 0 No <br /> Clay Gray 94 107 Grout Material X Neat cement 0 Bentonite y <br /> from 6 to 30,X 8 0 yds. Ix bags <br /> from to ft. ❑ yds. ❑ bags <br /> Gravel/Sand Mixed 107 137 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? 0 Yes 0 No <br /> PUMP <br /> 0 Not installed Date installed 6/29/94 <br /> Manufacturer's name Moyers <br /> <'.-` -.` Model number HP 1 Volts <br /> Length of drop pipe ® ft. Capacity 15 g.p.m. <br /> Pressure Tank Capacity 40 gal . <br /> Type: IX 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)? ❑ Yes X No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> C `'C The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,ifn EcE' EQ Stevens Drilling &Env., Inc. 86654 <br /> REMARKS,ELEVATION,SOURCE OF DAIAj,'efp. 1 Inn A Licensee Business Name Lic.or Reg.No. <br /> \R\F\f{u(� JJ`F .-c-k a 44415/94 <br /> GayOF ORONO Authorized Representative Signature Date <br /> Michael Stevens <br /> Name of Driller Date <br /> LOCAL COPY 5 3 0 2 8 7 HE-01205-04(Rev.5/92) <br />