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- � � ,- / MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. WELL LOCATION ' CountyName WELL AND BORWG RECORD 6 5 5 0 3 2 Henne in Minnesofa Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. ; Orono I 1 �3 �� °�� 2 3 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug � � ❑ Auger �Rotary G Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ ___.__ _ .. /� (�J ,..�howing property lines, _ f�A/ s'�j'1�! l'�J ) roads and buiidings. DRILLING FLUID WELL HYDROFRACTURED? ❑VES �NO N � � � � � FROM n.to n. -,- -;- -,-- -,- -�....�_� �~ USE C Monitoring ❑ Heating/Cooling i i i � �Domestic � ❑ Community PWS ❑ Industry/Commercial -�- -�- -+�- -i- ,� Irrigation i i i i ❑ Noncommunity PWS ❑ Remedial _ yy E T �] Environ.Bore Hole � i i i � , ❑ Dewatering ❑ i -, i i '/ZIM1e x CASING Drive Shoe? ❑ Yes �No HOLE DIAM. _� i i _�_ � / / ❑ Steel ❑ Threaded ❑ Welded i i i i �M1/G�G,. �Plastic ❑ S �1 Mile� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME __�b in.to__�_'��_ft. __a_�_�S Ibs./ft ��n.to�tt. ___ in.to _. ft. --_.--- IbsJR in.tOf"1 J.ft. in.to__ ft. Ibs./ft. ��n.to ��{ft. Property owner's mailing address if different than well location address indicated above. — - - ------ 4100 Berkshire is�Qe SCREEN�t� OPENHOLE PI mouth MN 5544b Make_�ns—_, steel �'°m .___"`° n. Y � Type ��Z�i��s Diam � SIoUGauze ��_l_V Length Set between ft.and tt. FITTIN S � STATIC WATER LEVEL WELL OWNER'S NAME --_IZ_a__ ___—ft.�.below ❑ above land surface Date measured_'��_�' �� Q PUMPING LEVEL(below land surface) � ' ' Well owner's mailing address if ditterent than property owner's address indicated above. �.2�_,.__ ft. after , _.__ 2 hrs.pumping �_g.p.m. �� � � WELL HEAD COMPLETION �PiUessadaptermanufacturer V�'1'� }AVAtA1'._ MOd21 ❑ Casing Protection _._. .. __. �12 in.above grade - ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �l Yes ❑ No HARDNESS OF Grout Material C' Neat cement ❑ Bentoni�e ❑ Concrete High Solids Bentonite GEOLOGICA�MATERIALS COLOR MATERIAL FROM TO � from___�to___��. ___.�.�_�❑ yds.,,�bags from to_ ft. bags topsoi2 blacic aft 0 3 —�- �� °tar-��_��P from_ to ft. � ds ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION � CIa� yellow �l� � 3� f�-� feet -> i'i _� : ri� _direction Sc�eTrype Well disinfected upon completion? tGl Yes ❑ No l" cl$y/boulder gray edium 38 15� P�MP ` 4 ❑ Notinstalled Dateinstalled __ 12��1�Q� _- r4 o . _ _._._.__. sand, fine g�$y Olt �S� 1Q0 Manufacturer'sname ---C��de— _- - _ __ Model number HP Volts ��11 clay brovn ediu� 180 220 � � Length of drop pipe__.��_�_ fl. Capacity ______ __g.p.m. sand/gravel brown �ft 220 23t� Type �Submersible � LS.Turbine ❑ Reciprocating ❑ Jet ❑ __ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes y�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes �YNo TNri WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. ' �-� �rC��— . 9 ---� 71 1(. Licensee�ess Name Li. r � , . �. .C , ��n n _ _ _ �� Aut~orrzed e sen ive ig��e --�-� � Dafev— Chuck Moore 11-29-00 -- _ _. ____ , 6 5 5 0 3 2 Name o�Driller Date LOCAL COPY HE-01205-07(Rev.2/99)