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� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIG <br /> CountyName WELL AND BORING RECORD � � 5 f- <br /> Hennepin � Minnesota Statutes Chapter 1031 �-' <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> W�i���E�'�. Ora o 117 �3 3 ,,. y .,, 343 " 6/9/97 �I <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD �, <br /> 1$Z�} �O]C Street ❑ CableTool ❑ Driven ❑ Dug � <br /> ❑ Auger O�iotary ❑ Jetted <br /> Show exact location of well in section grid with"X".� Sketch map of well location. ❑ � <br /> Showing property lines, ; <br /> { `o� � road�ppdtibuildings. DRILLING FLUID <br /> " ,� � ' :� Water ', <br /> � � � � I <br /> -; -;- -;- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i � �omestic ❑ Communi PWS <br /> -�- --�- -L- -�- i`; ❑ Irrigation � ❑ Industry/Commercial <br /> i i i i j ... ❑ Noncommunity PWS ❑ Remedial <br /> w i I I e `_....---- ; , ❑ Test Well ❑ Dewatering ❑ <br /> -r --t- -r- -r T _y,-t l:'�. . <br /> i i i - i +/ZM a t f 1�- "' CASING Ddve Shoe? O�es ❑ No HOLE DIAM. <br /> _i i _L_ _i_ � C�X 6 tee l ❑ T hrea d e d O 7;Ne l de d <br /> i -i- i i <br /> ❑ Plastic ❑ <br /> S <br /> �1 M�le�� y� <br /> `��}� i� CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 6 in.to Z�2 fl. Ibs./ft. � �,ro24 2tt <br /> �r11C� �. ki�nke in.to n. ibs.in. 6 �n.to�4 3n. <br /> Property owner's mailing address if different than well Ixation address indicated above. in.to ft. Ibs./ft. in.to_tt. <br /> ISZU F02C .StrS�t SCREEN OPEN OLE <br /> Wayzata, MN 55391-933I Make from �42 n.to 343 h. <br /> Type Diam. <br /> SIoVGauze Length <br /> Set beNveen ft.and ft. FITTINGS: <br /> STATI WATER LEVEL / <br /> WELL OWNER'S NAME �3 ft. ❑ below ❑ above land surface Date measured 6�1� 7 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. atter hrs.pumping 2�{� �' g.p.m. <br /> WELL HEAD COMPLETION <br /> C�Pitless adapter manufacturer Mt�$r51 Model <br /> ❑ Casing Protection q1Q2 in.above grade <br /> ❑ Abgrade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material [JQJeat cement ❑ Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from�to�Z_R. � ❑ yds. �$ags <br /> from to ft. ❑ yds. ❑ bags <br /> C 1 a y' y e 11 a w 1 from co n. ❑ yas. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay brOW]1 1 ,4 feet direction type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> clay <br /> �aaxs#x�x�xx� r� 4 g PUMP 6 j 12/9 7 <br /> ❑ Not installed Date installed <br /> �f Manufacturer's name �'Ou�d <br /> tav�l & s�nd r@ 6 ` Modelnumber HP �l Volts <br /> Length of drop pipe ZL^ff ft. Capaciry S� g.p.m. <br /> L'�.d & ravel �re 7 8 PressureTankCapaciry 5,��0 <br /> Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> cla re � I O ABANDONED WELLS <br /> Dces property have any not in use and not sealed well(s)? ❑ Yes CJ No �� . . - - <br /> Cla brown �� 1` VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes Ca/IVo <br /> sand b cla red 22 15 <br /> WELL CONTRACTOR CERTIFICATION <br /> * <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4�25. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best ot my knowledge. <br /> S <br /> �.S"@@ AttBC�'3eC� 5�1£et �censeeeusnress am rc.or eg. o. <br /> t ° ! <br /> � � _ � (�r,;��c; ��� � <br /> Authonzed Representative Signature Dafe ' <br /> Randy Jo�n�zon <br /> d.,� Name o/Onller Date <br /> �.�-' � �' � �, �: <br /> � � ` � � " HE-01205-05(Rev.1/95) <br />