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MINNESOTA UNIQUE WELL <br /> WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> (Aunty Name WELL AND BORING RECORD 7 3 8 3 6 <br /> Hennepin Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 118 23 27 ,,, ,,, ,,, 182 ft. 512-06 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> ❑Cable Tool Dag riven O Dug <br /> Longitude degrees minutes seconds ❑Auger :, otary ❑Jetted <br /> House Number,Street Name,City,and Zip <br /> lCode�of356 <br /> Well LocatiioonCor Fire Number ❑ <br /> 1849 West Rd, Orono 55DRILLING FLUID WELL HYDROFRACTURED? ❑Yes-80oShow exact location of well/boring in section g d with"X." Sketch map of well location. bentonite From ft.To ft. <br /> Showing property lines, USE -Kiomestic ❑Monitoring ❑Heating/Cooling <br /> N roads,buildings, 9 9 <br /> I and direction. ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> i-----.j__ -- <br /> j --' . ❑Community PWS ❑Irrigation ❑Remedial <br /> I .. - 4 r, ❑Elevator ❑Dewatering ❑ <br /> \ ',A CASING MATERIAL Drive Shoe? ❑Yes Xfo HOLE DIAM. <br /> W t ; 1 ET ' CISteel ❑Threaded ❑Welded <br /> i i 'h Mile �i\ lastic ❑ <br /> ,04 CASING <br /> 1 • <br /> W <br /> Diameter Weight Specifications <br /> i i r— 4 174 L <br /> I--1 Mile---I !t 30 <br /> in.to ft. lbs./ft. 8 in to ff <br /> in.to ft. • lbs./ft. in.to_vise <br /> PROPETY OWNER'S NAME/COMPANY NAME <br /> in.to ft. lbs./ft. n,to ft. <br /> Anthony SCREEN -r OPEN HOLE <br /> Property owner's <br /> mailing address if diff‘rent than well location address indicated above. Make Jdmson From ft.To ft. <br /> 4100 Berkshire Lane Type Steal PRA Mitt Diam. 2" <br /> Plymouth, MN 55446 Slot/Gauze .Qi0 Length 411 + 4; <br /> Set between 174 ft.and 182 ft. FITTINGS 2b]G6�F kp <br /> �t w/ <br /> STA ATER LEVEL q #w}+ <br /> ft.Selow ❑Above land surface Date measured 5-2--06 <br /> PUlalfj,(pIG LEVEL(below land surface <br /> WELUBORING OWNER'S NAME/COMPANY NAME j <br /> ft.after hrs.pumping g.p.m. <br /> ELL HEAD COMPLETION . h wa e� <br /> Well/boring owner's mailing address if different than property owner's address indicated above. itless Adapter Manufacturer�/�/,} •1 �M del <br /> El-Casing Protection �.2 in ab"ove grade " <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 'Yes ❑No <br /> Grout materials ❑Neat cement Kentonite ❑Concrete ❑Other <br /> From_XL To ft. _ ❑Yds. ❑Bags <br /> From _To ft. natural_fin ❑Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS <br /> OF FROM TO From To ft. ❑Yds. ❑Bags <br /> MATERIANEAREST KNOWN SOURCE OF CONTAMINATION <br /> topsoil black soft 0 90 feet direction^ . type <br /> Well disinfected upon completion?.f��/Yes ❑No C14.tii <br /> PUMP J ' 41, V F` <br /> clay/sand gray 170 C7 Not installed Date instilled <br /> watersand gray medium 170 182 Manufacturer's name sq" r O Q <br /> Model Number , HP�� —5 Volts C:7 ---3°C:7 ---3°Length of drop pipe /4:::: &/4:::: &/ ft. Capacity , g.p.m. <br /> Type:‘bmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes 'No <br /> VARIANCE ✓,,/ <br /> Was a variance granted from the MDH for this well? ❑Yes.Lat to TN# <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. R,._ 9 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling Co,. Inc. 271 j2 <br /> I_'icensee Business Name _ _- . - Lic.ori Reg.No. G <br /> r <br /> Aut,P e.IP::.r enta ive Signature Date <br /> Jim_ ate'' <br /> LOCAL COPY <br /> 7 3 913 6 Name of Driller <br /> HE-01205-09(Rev.9/05) <br /> IC 140-0020 <br />