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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 4 2 9 7� <br /> Hennepin Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Orono 117 23 30 NW�,SE,.AiW ,,. 168 6/04/dfl <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 2120 Carzis e L�tle s �ono, MN 5532 ❑ CableTool ❑ Driven ❑ Dug <br /> g ❑ Auger [�Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �NO <br /> N <br /> _� � � �_ r.c����� water FROM h �o n. <br /> i -i- -i- -, �. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> � � i � Domestic ❑ Communi PWS <br /> �- ❑ Irrigation �' ❑ Industry/Commercial <br /> � i -� i `.. ❑ NoncommunityPWS ❑ Remedial <br /> yr E T �� ❑ Environ.Bore Hole <br /> i � � � ,� . . ❑ Dewatering ❑ <br /> i i i r '/zIM.1e j�L�� CASING Drive Shoe? ❑ Yes CXNo HOLE DIAM. .� <br /> � � � f�EJ.:I�-� ❑ Steel ❑ Threaded ❑ Welded ( <br /> - -L- -�- <br /> i - i- i i <br /> � Plastic ❑ a�np[1 <br /> s <br /> �-1 Mile-� <br /> � � � CASING DIAMETER WEIGHT <br /> PROPERTY OWNEfI'S NAME �i in.to 163 ft. Ibs./ft. ��.td�s ft. <br /> Pillttr Hotge s ��.�o- __—n. ib5.in. �y colb$_n. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br />.__,. 1'15 Lgk� StLC�,a� W• SCREEN jf�a OPEN HOLE <br /> WB�ZdtS� A�t 55391 Make j.'Q from ft.to ft. <br /> Type Diam. <br /> SIoUGauze 1 Length <br /> Set between �3 fl.and��ft. FITTINGS: � PRC�P_T <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME Sd ft.� below ❑ above land surface Date measured 4!4/d0 <br /> - Piliar �O�S PUMPING LEVEL(below land surface) n� <br /> � <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION � <br /> ][I Pitlessadap[ermanufacturer�$$g Model b�� <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 �I Bentonite O Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from_�_to_��ft. � p yds.XI bags <br /> from [o ft. ❑ yds. ❑ bags <br /> Ci�R31 Yel3ov d ZS from ro ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION Tk �� <br /> C2ay Grmp 15 5� teet direction __ type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> Clay b Gravel Gray SO 79 PUMP 4/16/OD <br /> ❑ Not installed Date installed <br /> ri�.Ay Gray 79 I11 ManufacturePs name _ �eL8 <br /> Model number HP 1 Volts <br /> Clap � Gravel Red 111 160 Length of drop pipe 80 tt. Capaciry 2d g.p.m. <br /> Gravel � S�nd ��'d 16� ibg Type l�(Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS [T11 OidL1 <br /> Does propeRy have any not in use and not sealed well(s)? ❑ Ves ❑ No <br /> VARIANCE <br /> Was a variance granted from the MDH foi this well? ❑ Yes ❑ No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il 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 /> Stevens Dri121ng & Env. Services 86654 <br /> Licensee Business Name Lic.or Reg.No. <br /> _` <br /> Authorized Representative Signature Date <br /> ��ay .rot�soa �/oa/oo <br /> Name ol Driller Date <br /> LOCAL COPY '�j 4 2 9 7 6 HE-01205-07(Rev.2/99) <br />