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t . - WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH ' MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD �� j = �iennepin Minnesota Statutes Chapter 1031 � " `,�O O � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. Orono 117 23 0 � House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD Cl CableTool ❑ Driven �-1 Dug 2695 Deer I�tt1I1 Traii 8a8t Or0 O MN. ❑ n�9e� �7 Rotary �� ened Show exact location of well in section r "X". Sketch map ot well location. ❑ __ __ _ 5g356 Showing property lines, roads and buildings. DRILLING FW ID WELL HYDROFRACTURED? [-7 YES NO N i i i i �'.� FROM ft.to ft. _i _i_ _i_ _i_ USE ❑ Monitoring ❑ Heating/Cooling i i i � � omestic � ❑ Community PWS ❑ Indust /Commercial _i_ _�_ _i_ _i_ ❑ Irrigation ry i i i i ��r� �� ❑ Noncommunity PWS ❑ Remedial w E ��-R✓-��..F, �, _sy ❑ Emiron.Bore Hole ❑ Dewatering n � ,�:� i � i -r �'� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. '/zMee" _i i _i _ i_ . ^-y^� ❑ Steel G Threaded ❑ Welded � -�- � � 1:.. �.� . �7 Plastic ❑ �—i M�ie—� .. 4 �.,,....� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �__ in.to_��_tt. Ibs./ft. .� .r�� in.to_ . _ fL ___.__._._ ___.Ibs./ft �in.tq_c_.�ft. Property owner's mailing address if diflerent than well location addr s n cated above. ..._—___—in.to _ _ R. _ _Ibs./ft. __in.t 1��ft. 18340 Ninnetonka �1�d• SCREEN OPEN HOLE Make Jnhnsen from ft.to ft. WaY'l.�t"r�♦ �. 55391 7ype—_5��3#�$��S��e�—Diam. _ �-_�$�� � SIoVGauze� L.ength� Set between ��_ ft.and��_ft. FITTINGS:7A� v e$de STATIC WATER LEVEL X�J[—j�$ ifB= WELL OWNER'S NAME �_Q______ ft.� below C above land surtace Date measured;��_�d� PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. � _'rfe __.__ft. after ,___ _1 _ _hrs.pumping___2_�___ q.p.m. WELL HEAD COMPLETION " t�Pitlessadaptermanufacturer��__ Model _.___________ ❑ Casing Protection_ � 12 in.above grade ❑ At-grade(Emironmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? f�Yes I I No HARDNESS OF Grout Material G Neat cement f� Bentonite ❑ Concrete � High Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO q ,y from 0 . to .70._ft. _�_ ___ ❑ yds. ipbags from��_ _to__�..5.�t. ��.tus►$�r' yds. ❑ bags Cl� Ye110Y S • 1 ' f�om - �o h ❑ vas. o bags NEARE T KNOWN SOURCE OF CONTAMINATION Cla Gra S 1 � f - �� feet SDu�h _direction S �t;c� _type Well disinfected upon completion? �l Yes ❑ No Gravel & Cia Gra g . 1 •PUMP ❑ Not installed Date installed ��_�rOo Gravel � CZa �r0 � �Manufacturer'sname __ _ ___ ___ __ _____ Model number _ _ HP �.�._ Volts 7�n SaAd � �Length of drop pipe 1�� ft. Capacity __ __ ___g.p.m. Type: �($ubmersible ❑ l.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �'i No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes � No TNk WELL CONTRACTOR CERTIFICATION Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The information contained in this report is true to the best of my knowledge. D4N STODOL�i iiF.LL DHILLING CO• •-� i�. � L�ensee B iness Name , , Lic.or Reg.No. ��q g �,." I L 11-29-OU - ----—__-- ---- � ufhorize ep senta iv ign ure' Date Duane Mathe�►s 9-1-00 Name ol Drdler� Date LOCAL COPY 6 � 5 0 0 3 HE-01205-07(Rev.2/99)