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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ' �o��YName WELL AND BORING RECORD � 5 5 0 3 8 Henne pin ,� Minnesota Statutes Chapte�1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed tt. Orono I17 23 10 ,. �. ,. I78 I1-6-00 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD q ❑ Cable Tool ❑ Driven Cl Dug 2125 Carria e Lane �r��Q SJ56 7 Auger �.Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch rr1ap�(well location. ❑ _ _. �krdwing p perty lines, {F� roads an�buildings. DRILLING FLUID � � � WELL HYDROFRACTURED? ❑�YES�10 _ N _ '�l � , , , , ., su er el—g FROM • ft.to h. ; -,- -;- -� � , �--^' \ USE f:] Monitoring ❑ Heating/Cooling i � i i �+ omestic "`., �-•�� s�� ❑ Community PWS [] Industry/Commercial _i_ _a_ _x_ _i_ '^' 9 �\'� , ❑ Irrigation yy � � � � E T � �.�� ❑ Environ.Bore Hole � Noncommunity PWS ❑ Remedial i i i i ❑ Dewatering ❑ -� -,- -r- -� ��ZIM.1e � CASING Drive Shoe? ❑ Yes �No HOLE DIAM. _i i � i_ � ,� ❑ Steel ❑ Threaded ❑ Welded i _ i_ _i _ _i ),�Plastic ❑ S �--1 Mile� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME _��_in.to�_�_�n. �r�r 71 Ibs./n. ��g__� JOri Roh s Cons t ruc t f on _—�n.to __ft. _ __ IbsJfl. j 1 {n.to�y Q� Property owner's mailing address if different than well location address indicated above. in.to__.. ft. ___IbsJft. in.to tt. 600 Rwy 169 S, �1 S S SCREEN OPEN HOLE St Louis Park, F�T 55�+26 Make_Johnson ��om h.�o h. ` � Type �FA �e�� atoe� Diam. � SIoVGauze Orl�t A ...__.._—Length /�T�.L___ __ �� iva� Set between tt.and ft. FITTINGS: STATIC WLA'TER LEVEL WELL OWNER'S NAME ____._57�ft.�below ❑ above land surface Date measured_1.1.��Q PUMyPING LEVEL(below land surface) _ Well owner's mailing address if different than property owner's address indicated above. 1 60 ft. after ___�__ hrs.pumping__3_� g.p.m. � �W LL HEAD COMPLETION Pitlessadaptermanufacturer��_��$_�_�� Model _ :. � ❑ Casing Protec[ion___.. __ ._____. l�'�12 in.above grade �i. ❑ At-grade(Environmental Wells and Borings ONLY) j�` GROUTING INFORMATION Well grouted? �Yes ❑ No �'��4:. HARDNESS OF Grout Material ❑ Neat cement f7 Bentonite ❑ Concrete i h Solids Bentonite GEOLOGICAL MATERIALS COLOR FROM TO '�9 I. MATERIAL � to_ �h ___�_ ❑ yds.�bags from_ v * from—�V—to_i_-f-73__ft. na t_�_r�t-_t'lyis3O bags �.� C�By J��1�� a��t 0 � from to ft. ❑ yds. ❑ bags - — }_ NEAREST KNOWN SOURCE OF CONTAMINATION C183► gr8�7 SofC 2� 5 _� ��__ _feet ' 7 � direction ��l [j�.C:._ _type � Well disinfected upon campletion? �Yes ❑ No , clay/�ravel gray soft 58 9 PUMP ❑ Notinstalled Dateinstalled 2�23��1 clay gray soft 90 11.4 Manufacturer's name __ A e..�.,.�.... ___.._. '� .r[cLmV{�V�-_ gravel/clay gray soft it� 138 "'�de��mbe� _ HP�� o�ts_ .��_ Length of drop pipe_ _�,.26 ft. Capacity _.__g.p.m. clap/ssnd broWn .40�� 138 lb3 Type �Submersible f� LS Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS sand/grsve 1 col ored S�f t �,63 16$ Does property have any not in use and not sealed well(s)? ❑ Yes ;�'No VARIANCE sand broWn $�t C 1 68 1�8 Was a variance granted from the MDH tor this well? ❑ Yes �'No TN#_ E WELL CONTRACTOR CERTIFICATION Use a second sheet if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to ihe best of my knowledge. Ql1 S C A(�A 1 A L�TP� � �}��.]��.�,,�,,,--�V+ �b� 2 - Licensee 8usiness Name — L�c.or Re .No. �,//�_�� ,i,.-r � 'r --- ��`26�'V�. . Authorized Representahve Signature Date . Duane Mathews 11-6-00 Name of Driller Date LOCAL COPY 6 5 5 0 3 8 HE-01205-07(Rev.?J99)