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.. " ' r <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> - CountyName WELL AND BORING RECORD � 9 -�� L ? <br /> fi�nnepin Minnesota Statutes Chapter 703/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 �6 ,. ,. , �OS " 5-22-9� <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 4725 Bayside �d.� �rOtl� 553 9 ❑ CableTool ��l Diven ❑ Dug <br /> ❑ Auger �3'flotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. C7 <br /> Showing property lines, <br /> � u�r j�E roads and buildings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES �'MO <br /> " �(,� R, t� �t t3 it t O II l t 4� <br /> , , i , 1�� /�Q FROM__ ft.to ft. <br /> i _i_ _i_ _i ��, <br /> � USE / ❑ Monitoring ❑ Heating/Cooling <br /> i i i i \ '6 Domestic <br /> i � � _i_ ❑ Community PWS ❑ Industry/Commercial <br /> � i � i ❑ Irrigation ❑ Noncommunity PWS ❑ Remedial <br /> w E T ❑ Test Well <br /> � � i i 1 ❑ Dewatering ❑ <br /> i i i i �2IM_�e �6`"' CASING�' Dri�ve!Shoe? Yes ❑ No HOLE DIAM. <br /> _i_ _ i_ _i_ _i_ I ,K�`-� y�steel .�[J'Threaded ❑ Welded <br /> � � � � l �� <br /> ❑ Plastic ❑ <br /> s <br /> �1 Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to �'�� ft. j'1 Ibs./ft. ��-�—in.to 34 <br /> Aiaraan Builders in.to ft. Ibs/ft ��f"4 in.to�. <br /> Property owner's mailing address it different than well location address indicated above. in.to ft. Ibs./ft. y, �i f$��, <br /> 13233 Hudson Rd SCREEN OPEN HOs1LE L <br /> Aftan, C�l�t 15V01 Make from L�v ft.to 305 ft. <br /> Type Diam. <br /> SIoVGauze Length <br /> Set between ft.and R. FITTINGS: <br /> - STATI6 V(,4iER LEVEL . ���}��,n <br /> r <br /> WELL OWNER'S NAME 1 {� ft.�below ❑ above land surface Date measured L � <br /> PUMPING LEVEL(below land surface) <br /> Well owneYs mailing address if diRerent than property owner's address indicated above. Z�s ft. after 3 hrs.pumping �� g.p.m. <br /> WELL HEAD COMPLETION Whi tewa ter <br /> ,,E�A Pitless adapter manufacturer Model <br /> ❑ Casing Protection ,�12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ,� Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete ,p5 High So�ids Bentonite <br /> MATERIAL g <br /> from�to�ft. .,7�� ❑ yds.�`bags <br /> n n from_�_to'�,(��_ft. �8��_�J�y�s10 bags <br /> C��� �irown $�f� �! 7 from to tt. ❑ yds. ❑ bags <br /> NEAFC�./[/�JJyC N SOURCE OF CO INATIOpL��J/ �7'� <br /> C�.Bp �r8y $�ff C�� �,(} / v feet ��v� rl direction ��� / j�rrype <br /> J <br /> Well disinfected upon completion? �Yes ❑ No <br /> �ravel colored mediur� 140 16 PUMP <br /> ❑ Not installed Date installed �����J� <br /> CZS� �;ray $Qf� 1�� 2� Manufacturer'snaeme �e� `��'C��t <br /> 1., �1�y Model number D� _039 HP � Volts <br /> clay!sand L1��� g�f� L 1� �� Len th of dro i e ft. Ca aci <br /> 9 P P p P b' 9.p.m. <br /> r� Type:�l Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ehale ��reen sof t 240 24 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �No <br /> sandstone rra w/ t�srd 2�6 3d <br /> VARIANCE <br /> lack sp cks <br /> Was a variance granted from the MDH for this well? ❑ Yes `�No <br /> / <br /> WELL CONTRACTOR CERTIF�CATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> �on Stodola j°�ellDri2lin�; Co. , I��c. <br /> L�censge Busines/s Name a Lic.or Reg.No. <br /> �..f f��✓'f�.:../��" �:`��-�"''�.,��j�� L7��3�7L� <br /> � Authorized Representative Signature Date <br /> Chuck t�ioore �-21-��5 <br /> Name of Dri/ler Date 9�6) <br /> LOCALCOPY 597222 <br />