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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 5 - <br /> Aennepin Minnesota Statutes Chapfer f031 <br /> Township Name Township No. Range No. Section No. Fr ction WELL DEPTH(completed) Date Work Completed °"1 <br /> Orono i18 23 33 " '�� <br /> �((f,.a -�(,f,� 2121 04/15/00 ` ; � <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Du �' � <br />_ 195 Crysta2 Creek, Orono MN 55323 �Rotary ❑ � �'� �' � � <br /> � <br /> ❑ Auger �t <br /> Show exact location of well in section grid with"X". �!'�ltSketch map of well location. ❑ �' J <br /> � Showing property lines. <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? �� ES � O <br /> N " � <br /> , , , , . Water FROM n.�o � n. <br /> -� -�- -�- -�_ l�o i+ USE ❑ Monitorin <br /> i i i � �� � �omestic 9 ❑ Heating/Coolin <br /> _i_ �_ _�_ __ � ❑ Community PWS ❑ Industry/Commercial <br /> i i i ❑ Irrigation ❑ Noncommuni PWS <br /> y,r E T ❑ Environ.Bore Hole Ty ❑ Remedial <br /> � � i � ❑ Dewatering ❑ <br /> i i i -� ,2IM e CASING Drive Shoe? ❑ Yes o HOLE DIAM. <br /> � i_ _L_ _i_ I ❑ Steel ❑ T readed O Welded <br /> � � � � 1 [�(Plastic C��luea <br /> S <br /> �-1 Mile—� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �1 ;,, �0 116 ft. Ibs./n. 1�„�to 45h, <br /> Pi11aZ HomeB m.to n. ibs.in. 1/,{�0 121tt. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> 125 take S[reet W Make $yC� trom ft.to ft. <br /> W831ZSt$� MN 55391 Type PVC Diam. <br /> Sbt/Gauze Length 5� <br /> set between 1 I5 ft.and I21 ft. FITTING�s� <br /> STATIC�TER LEVEL �►�1 S�OO <br /> WELL OWNER'S NAME ft.�below ❑ above land surtace Date measured <br /> Pillax HO�S PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping �0 g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑ Pitless adapter manufacturer �188 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 /> HARDNESS OF Grout Material ❑ Neat cemef,�( [�RBentoryt� ❑ Concrete ❑3igh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO U 4 <br /> from to ft. ❑ yds.�,bags <br /> from to fl. ❑ yds. ❑ bags <br /> Clt�y Yellow 0 13 from co e. ❑ YaS. ❑ bags <br /> NEAREST KNOWN SOUFiCE OF CONTAMINATION � <br /> Clay b Sand Gray 13 35 feet direction rype <br /> Well disinfected upon completion? �Yes ❑ No <br /> Ci1Sy Gray �S 7� PUMP <br /> ❑ Notinstalled Dateinstalled 4/15/00 <br /> �'.18y � aS8IIt1 Gray 9� 1�0 Manufacturers name ��r <br /> A Model number HP 1 Volts <br /> n Sand & Gravel V='Sp 10� i Z 1 Length of drop pipe Q k. Capacity 12 g.p.m. <br /> Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Ves (�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �No TNfY <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 con[ained in this report is true to the best of my knowledge. <br /> Stevens Drilling 6 Enn. Services 86654 <br /> Licensee Business Name Lic.or Reg.No. <br /> � "^- . <br /> Authorized Representative Signature Date <br /> Randy Johnson Q4/15/00 <br /> 6 4 2 9 7 5 Name ol Driller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />