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!� . <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 6 8 0 2 6 <br /> Rennepin Minnesota Statutes Chapter f03/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono lI7 23 09 ,, „ 245 n 8-28-Di <br /> House Number,Street Name.City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 26$5 N Shore Dr, Orono, MN 5391 C7 CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �Rotary �1 Jetted <br /> �: Show exact location of well in section grid witn"X'. �SkBJch map of weil location. ❑ ,_ _ � ___ <br /> �howing property lines, - <br /> �� ;� % . �lrpads and bwldings. DRILLING FLUID WELL HYDROFRACTURED? :-.]YES O <br /> N - � .._�, —� . <br /> + �a t�r FROM __k.to ft. <br /> i -i- -i- -� <br /> USE 'f ❑ Monitoring [7 Heating/Cooling <br /> i i i i L'J Domestic ❑ Communit PWS <br /> ❑ Irrigation Y f7 Industry/Commercial <br /> i i y i -��--- ❑ Noncommunit PWS <br /> w E T � ❑ Environ.Bore Hole Y ❑ Remedial <br /> i i i i .,,� ,/ ❑ Dewatering n <br /> i , i r �/zIM1e ____"_'_ CASING Drive Shoe? Yes ❑ No HOLE DIAM. <br /> _i_ _i_ _i_ _i_ � � � ��, �Steel �Threaded — ❑ Welded - <br /> � � � ' ❑ Plastic ❑ <br /> �1 M�ile� _, �...� <br /> CASING`DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME `� in.to 233 ry. 1.� Ibs./ft. 8 in.to 3 <br /> Erotas Building Corp• __in.to ft. Ibs/R �in to.�f� <br /> Property owner's mailing address if different than well location address indicated above. _ in.to R _. ______Ibs./ft. ����__,''� g <br /> 2193� H3nnetonka B1Fd SCREEN OPEN <br /> Excelsior, MN 55331 Make._- f,om � ,,.,0 245 � ; <br /> Type Diam. ___ <br /> SIoVGauze Length . <br /> Set between ft.and ft. FITTINGS: � <br /> STATIC��R LEVEL <br /> WELL OWNER'S NAME _._ __ _ ft. �below ❑ above land surface Date measured_ �����0� <br /> PU�Ij�C�L�//�L�(�pjow land surtace)�f� j'� <br /> Well owner's mailing address if different than property owner's address indicated above. L�• L�� fl. after ` ______hrs.pumping �`+��� g.p.m. <br /> W�LL HEAD COMPLETION <br /> ��Pitless adapter manufacturer whi t ewa t� Model <br /> �."7 Casing Protection _ __ ____�12 in.above grade <br /> L� At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �2�Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cemery,� f� Bento��❑ Concrete�L�High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from__ �j to�i ft. -4 Q❑tyds t�bags <br /> from � to L 31 ft. n8��.�$�_ Sl.y�.l� bags <br /> el8y yellov �tf��t2tA 1 r�om_ �o n. ❑ yds ❑ bags <br /> NEARE��NSOURCEOFCONT9�fy11NFyTl �+ ` /j � , � <br /> c2ay/aand gray soft 1 22 feet �S%�"'� f direction ` � type <br /> re Well disinfected upon completion? C�Yes ❑ No S�[�J `�� <br /> —v <br /> shale/sandston yello mediu 22 24 PUMP <br /> Cl Not instalied Date installed ._______ �, ��1t�Q1 <br /> Manufacturer'sname lle=�.�Q�_.____._ _ _ <br /> Model number HP 1 s S Volts fr�� <br /> Length of drop pipe_. ._�� _.__ ft. Capacity g.p.m. <br /> Type: �Submersible G LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? G Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �No TN#. <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/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 Stodola W�11Drillin�o, . Inc.__2 172 <br /> ------- - <br /> DroQe cas ing 2' ice ee Business Name �Lic or Reg No. <br /> .,�- :�� - ..-. _ � �2-20-0 <br /> Authorized RepresenjStive Signature Date <br /> ehuck Moore �-2$-01 <br /> Name of Driller � Date <br /> _ LOCAL COPY � 6 6 8 0 2 6 <br /> HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />