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_ <br /> _. _ L �,�����.�.v, <br /> ;,, <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounryName WELL AND BORING RECORD ,, ,,' ,;. 6 4 31 g 3 <br /> H�nnepin Minnesota Statutes Chapter f03/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � , . � Date Work Completed <br /> Orono 118 23 35 �,. ,. ,, 140 " 5-25-40 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 1 Z�+Q L 8� ��/� �r�n0 5 5 39I ❑ Aug e Tool ❑ Driven ❑ Dug <br /> C�Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ _ <br /> Showing pr erty lines, <br /> roads an ildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> " N$t@C <br /> � � � � FROM n.to n. ` <br /> -; -;- -;- -r ; <br /> �� USE �./ ❑ Monitoring ❑ Heating/Cooling ; <br /> i i i i Ya Domestic ❑ Communiry PWS ❑ Industry/Commercial � <br /> -�- -�- -�- -�- ❑ Irrigation r <br /> i � i i � �� � � NoncommunityPWS ❑ Remedial r <br /> W E x � ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> i i i i T <br /> i _, i i ,�'Mie CASING DriveShoe? ❑ Yes No HOLEDIAM. <br /> _i _ i_ _L_ _i_ I � ❑ Steel ❑ Threaded ❑ Welded <br /> � � � � 1 J�` �Plastic ❑ <br /> �--t Mile-� � <br /> CASIN DIAMETER WEIGHT � <br /> P OPERTY OWNER'S NAME � in.to i�a ft. �"��� IbsJft. $ in. 0 3 <br /> �rchetype Builders Inc. ��� p �� <br /> +�.�o ft. Ibs./ft. s t <br /> � e owner's mailing address if different than well location address indicated above. _in.to ft. � Ibs./ft. in.to_ft. <br /> ��0 Quebec Ave N SCREEN,'O�n��� OPEN HOLE <br /> MinneBpolis, � S54L./ Make from ft.to ft. <br /> TYPe 8 � ��$ gteel Oiam. L <br /> SlotlGauze r 0 Length �� ♦' 4� - <br /> Set between L�� ft.and��ft. FITTINGS:__7 K���~_v_���� <br /> STATIC WATER LEVEL �� <br />� WELL OWNER'S NAME �5 ft. C�below ❑ above land surface Date measured���Q <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. �R ft. after 2 hrs.pumping��g.p.m. <br /> �WELLHEADCOMPLETION Whitewater Model <br /> Pitless adapter manufacturer <br /> ❑ Casing Protection �2 in,above grade <br /> ❑ At-grade(Environmental Welis and Borings ONLY) <br /> GROUTING INFORMATION � <br /> Well grouted?�'V'es 'Q No ,�� f ; <br /> HARDNESS OF Grout Material q N�at ce C�6en i Cl Concrete �High Solids Bentonite <br /> GEOLOGICALMATERIALS COLOR MATERIAL FROM TO ,;�' ,- � <br /> � ,�• .�em.�- _���' ..��.�-ft. �_�_� ❑ Yds.�bags <br /> from_,__,��'to�,ft. �as.�..�t BjvlslO bags <br /> «i�.f�i i:l l <br /> �.+la� from'� � -t9 ft. ❑ yds. ❑ bags <br /> NEARES r WN SOURCE OF CO AMI AUO S'eC�+� 1� <br /> ,�� f <br /> - • feet �����.�-�direction type - <br /> S Well disinfected upon completion? �'es ❑ No <br /> PUMP �����0 <br /> ❑ Not installed Date installed <br /> Manufacturer's name <br /> Model number HP ��� Volts 23� - <br /> Length of drop pipe O I ft. Capacity g.p.m. <br /> Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> i <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes .�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �lo TNk <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,eta The information contained in this report is true to the best of my knowledge. <br /> Don Stodo2.a Well Urill3ng Co. , Inc. 2 172 <br /> Licensee B iness Name J,ic.or Reg.No. <br />,.,._ ..r-�-�, <br /> j <br /> �_ s <br /> A thbrized'epre tativ�Signature Date <br /> Chuck Aioore 5-I5-OU <br /> 6 4 319 3 Name ol Dril/er Date <br /> LOCAL COPY HE-01205-07(Rev.?/99) <br />