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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br />County Name WELL AND BORING RECORD <br />Hennepin Minnesota Statutes Chapter 1031 5 7 2 71- 5 <br />Township Name Township No Range No. Sed�on No Fraction WELL DEPTH (completed) Date Work Completed <br />Orono 117 23 4 N W NW 118 8/20/96 <br />House Number, Street Name, City, and Zip Code of Well Location or Fire Number DRILLING METHOD <br />60 Cygnet Place Cable Tool Driven Dug <br />Auger %R Rotary Jetted <br />Show exact location of well in sccbon grid with ')(' Sketch map of well location <br />Showing property lines. <br />I !'\ roads and buildings DRILLING FLUID <br />ri <br />J Bentonite <br />' - - - - ' USE Monito <br />ring Heating Cooling <br />- - - - ` �I Domestic Communal Industry,ComfnWW <br />- - - - - - 1 mga 17 Ilon <br />J , -; Noncommunity PWS Remedial <br />w c n Test Wen Dewatenng --- -- <br />i CASING Drive Shoe? . Yes No HOLE Difill <br />n Stem Threaded Welded <br />' X Plastic . <br />S <br />CASING DIAMETER WEIGHT <br />PROPERTY OWNER'S NAME 4 at, to113 ft. this nl 8 n to 60" <br />ll <br />Don Currier in. to e. ____-_-_ lbs" -. n,o. Oft <br />Property owner'; mating address t different than well location address indicated above ... _ at. to h. Ibis M. _--_ _ n, to <br />SCREEN OPEN HOLE <br />Make Jawco from <br />Type PVC Dwn <br />Slot'Gauze _ _ 12 Level ---- - <br />Set between --3 ft. and_ 11. FITTMI(i3: _X Packer <br />STATIC WATER BLEVEL �r <br />WELL OWNER'S NAME _ ft. Xbeow n above land surface Date measures_ - <br />PUMPING L" (below land surface) 3 <br />Well owner's mailing Address it different than property owner's address mdx;ated above -- _ ft. after _-- __-- _ _ hrs pumping _ .._ _4Q <br />-g.p.m. <br />WELL HEAD COMPLETION <br />A Pitlessadaplermanutacturer�itewater__ del S-5-4 <br />L] Casing Protection---_--- ----- n 12 wi above grade <br />n At -grade (Emtronmental Wells and Borings ONLY) <br />GROUTING INFORMATION <br />Well grouted?] Yes ' : No <br />GEOLOGICAL MATICRIALS COLOR HARDNESS OF FROM TO Grout Material ' ' Neat cement A Bemonn U Concrete O High Sokla Be ntoorte <br />MATERIAL from 5010 n. n yds. n bags <br />clay brown wed. 0 20 from - ---- to -- _ _n. _ n yda n be" <br />fro._ -- __ 10 _-_ — n. _ n yda. n bew <br />clay blue e med . 20 49 NEAREST K N SOURCE OF CONTAMIVTION <br />,,,, `ij .sever pi <br />Well disinfected upon completion? X Yes No <br />sand & gravel mix med. 49 70 <br />PUMP 8/22/96 <br />'. Not mstalkW Dale � Mad _ --_-_---- <br />sandy clay blue med. 70 93 Manufacturers name Sta—Rte _ <br />Model number -___ S 7 5M --- _ HP / _ V <br />230 <br />r7 12 3 L h of dr TOO M. m• <br />sand Si gravel brown med . -� I �+ oPpp•__ _ mar -- as <br />Pressure Tank Capadty L 0 L _-- - _. <br />Type: XSubmersrble n L.S. Turbine '. Reciprocatug i ] Jet n -- <br />ABANDONED WELLS <br />Does property have any not in use and not sealed well(s)'i Yes X] No <br />VARIANCE <br />Was a variance granted from the MDH for this welly . Yen 41 No <br />WELL CONTRACTOR CERTIFICATION <br />Use a second street, it 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 />R.E.S. Well Drilling 27276 <br />Lbensee Buahesa Nama �/—f� - - Lic or Rey. No. /1 / <br />r - - Aullf-fdRapr.earw"SoWlee _ Date <br />Robert Be Stodola, Jr- 8/22/96 <br />Name of OAW Date <br />LOCAL COPY 572715 HE-012064116(Raw.I S) <br />