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,. __ _ .. , : . _ . _ ,., _ �. , .. ..._.. . ,� . �' r R WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. '� CountyName WELL AND BORING RECORD 6 5 5 0 4 6 Hennepin Minnesota Statutes Chapter f03! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed fl. Orono 118 23 35 ,. ,. ,. I30 1Z-1-00 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 1151J 7i.r �Sn xd Orono ❑ CableTool ❑ Driven i7 Dug � CJ Auger �l Rotary i.7 Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ ---. ..._ ------ ----..—...---- Showing property lines, �� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �O kN � � � , � � wa t e r FROM_ n.to K. � -; -;- -r- -,- USE ❑ Monitoring ❑ Heating/Cooling 1 _i_ _�_ _i_ _i_ .�,��_ � Domestic ❑ Community PWS ❑ Industry/Commercial F. i i i i � ❑ Irrigation ❑ Noncommunit PWS w E Q o ❑ Environ.Bore Hole Y ❑ Remedial ' i � i i x ❑ Dewatering ❑ �� i i i -r I � CASING Drive Shoe? '/2M1e ❑ Yes L7 No HOLE DIAM. _i _i_ _�_ _i_ I � ❑ Steel ❑ Threaded ❑ Welded r � � � 1 y p Plastic ❑ S �1 Mile� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME ��in.to��__e. _�,_r1� Ibs./tt. �_in.to�ft. J�S H�1Qe$ -----in.to-- _ _ ft. IbsJR �in td�_�ft. Property owner's mailing address if different than well loca[ion address indicated above. _—. in.to_ __ _ ___ft. Ibs./ft. in.to ft. `�Q � 79ti1 St � S�e 133 SCREEN_ OPENHOLE �►a�hass�en, MN 55317 Make_Johns��__ from ft.to ft. TYPe�i-a��-C-�-�—��s�—Diam. ?N — SIoUGauze A�n ______Length _ • Set between ft.and it. FITTING � STATIC WATER LEVEL WELL OWNER'S NAME b� ft.Ts�below ❑ above land surface Date measured�t—�_nQ PUMPING LEVEL(below land surface) Well owner's mailing address if diflerent than property owner's address indicated above. __�1 g _ft, after__L. ._,_ __ ____hrs.pumping_ � g.p.m. WELL HEAD COMPLETION �Pitless adapter man�i�e��_��r _ Model ___. ❑ Casing Protection_ _ _ __. _ ___ p 12 in.above grade Cl At-grade(Environmental Wells and Borings ONLY) � GROUTING INFORMATION Well grouted? �'l Yes ❑ No � GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material r� Neat cement ❑ Bentonite 'i Concrete ❑ High Solids Bentonite MATERIAL from Q _to__ .��t. ��__ ❑ yds ❑ bags from�,--_-to—��_"�t. �$�i+�Biy�.�7 bags (�+1a from _ __to _ft. _. _______ ❑ yds. ❑ bags �: NEAREST KNOWN SOURCE OF CONTAMINATION � � teet C�$ _��__— .��,��direction ��Rqpe Well disinfected upon wmpletion? '�] Yes ❑ No sand PUMP - C] Notinstalled Dateinstalled__.__._ �_�� Manufacturer'sname �Q�'}Q��Qj'_ _ _ ` �� Model number_. ._._ _ __ . , _ __ _,. __,_ HP . . _ Volts__�q-9�� - ..��-- G3V — Lengthotdroppipe.___S!L__ _ ft. Capacity ____ ___g.p.m. p�} Type: Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes ,�No VARIANCE Was a variance granted from the MDH for this well? u Yes I�lo TN# - 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. 7he information contained in this report is true to the best of my knowledge. D�n—�31-L1�ii►e�ess��Na e—�s—�"Lic ora�`ey�No��_ �� 72 ��_� 3-27-42 �Authorize Repr nt iv S nature� Date Chuek Moore 12-1-00 6 5 5 0 4 6 Name ol Driller Date LOCRL COPY HE-01205-07(Rev.2/99)