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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> h1.LOCAT F LCI 1• WATER WELL RECORD MINNESOTA UNIQUE WELL NO. 475707 75707 <br /> County for Water Sample <br /> Minnesota Statutes 156A.01-.08 <br /> Township Nat, ' Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> 117 °s` 23 w 02 NE SE NE 166' ft. 1-30-91 <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5.DRILLING METHOD <br /> 0 CableTool ❑Reverse 0 Driven ❑Dug <br /> 1250 4111 Avenue Orono, Minn. <br /> Show exact location of well in section grid with"X." Sketch ma of well location. ❑Hollow Rod 0 Air 0 Bored ❑ <br /> N <br /> 1 t Addition Name ]Rotary ❑Jetted 0 Power Auger <br /> -_r__y_ _' __t_ 6.DRILLING FLUID <br /> t <br /> I <br /> ---- -'- '---X Block Number ] 7. lL. <br /> W 1 r E �e'y•C !'�'� Domestic 0 Monitoring 0 Heat Pump <br /> I ' t Lot Number �Y 0 Irrigation 0 Public 0 Industry <br /> 1 h mi. •N��P Lt•CI Test Well CI Municipal O Commercial <br /> --1- -�- ---r- w ❑AirConditioning CIt ' I / <br /> I--I mile it,e).>:',:4 +••t i 1, t. sy v w . 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME MailingAddress if different thanpropertyaddress y� HEIGHT:Above/Below <br /> Black [S Threaded <br /> t ca +ion indicated above. Surface y ft. / <br /> 4. 1315 Fist Lake� Street C7 O Gal:. O Welded Drive Shoe? Yeses No 61/4 <br /> t t it ly Craig Wayzata, Minn. 55391 O PITic ❑ <br /> 4 - in.to 162 ft. Weight 10.86 lbs./ft. _in. to . <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. __in. tort. <br /> FORMATION <br /> in.to ft. Weight lbs./ft. —in. tort. <br /> Gravel 0 65 9.SCREEN Or open hole <br /> from ft.to. ft. <br /> CIII <br /> ClayMake �`' <br /> Cla 65 Zsri Type Stara 1'l akftS SS'fi ll Dtam. 4" <br /> Slot/Gauze Sand 1 2 10 Length FITTINGS: <br /> t! lfi6 Set between 162 ft.and 166 ft. <br /> •-a 10. TIC WATER LEVEL <br /> j� ft.CXelow 0 above Date Measured 1-30-91 <br /> land surface <br /> II.PUMPING LEVEL(below land surface) <br /> 110 ft.after 4 hrs.pumping 20 g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12.HEAD WELL COMPLETION g,� <br /> __ _ ---'` to tet Model <br /> __ X1 Pities adapter manufacturer <br /> r"•l� I CI Basement,offset XI At least 12"above ground <br /> ' c j 0 Plastic casing protection <br /> t ti- 13.WELL GROUTED? XYes 0 No <br /> •1 <br /> - <br /> 0 Neat Cement 0 Bentonite natural atriai1l <br /> Grout material from to ft.cu.yds. _ <br /> 1291. <br /> IAARZ2 • <br /> ^ 14.NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> - - feet direction type <br /> Well disinfected upon completion? a t'es O No <br /> 15. PUMP <br /> Date installed 2-6-91 O Not installed <br /> Manufacturer's name•Ownetrn • arundfo <br /> Model number t HP 3 Volts 230 <br /> Length of drop pipe 126 ft. Capacity g.p.m. <br /> Material of drop pipe 11/2" Galy. <br /> Type:Xj Submersible 0 L.S.Turbine 0 Reciprocating <br /> 0 Jet 0 Centrifugal Cl <br /> 16.ABANDONED WELLS <br /> Unused well on property?erraces <br /> es ❑No <br /> Use a second sheet,if needed Sealed Ai Permanent 0 Temporary ❑ Not sealed <br /> 17.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> DON =MLA WELL £9JLL16 co.. INC. 27172 <br /> Licensee Business Name y License No. <br /> Addressf <br /> .15306 Highway 77, t14n. 55345 <br /> sign er%. ' '7. i).„1-30-91 <br /> Authorized Representative <br /> F. P. McMahon Date 1-3((1-91 <br /> 475707 Name of Driller <br /> LOCAL COPY . 5/7430M <br /> 7/78 30M <br /> HE-01205-03(Rev.9/88) 2/82 M <br />