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. �:;:.._ . . __ _ �--,-- .. :��:.. _�� _ _ > „��' . .... . � • ' WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. `� CountyName WELL AND BORING RECORD� 6 4 g 212 � H Minnesota Statutes Chapter 103! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed v. i. v. Z�$ n 6�1.9"�� House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug ❑ Auger �otary ❑ Jetted Show exac�location of well in section gri with"X". Sketch map of well iceation. f-] _ � Sh wing prope, lines, �oads antr��u dings. DRILLWG FLUID WELL HYDROFRACTURED? ❑YES �NO N /' �.,. ; �.�,,, bentonite FROM h.�o h. � , � � -; -,- -r- -,- '_ .� USE ❑ Monitoring ❑ Heating/Cooling i i i i � 1a�Domestic ❑ Communit PWS _i_ _a_ _�_ _i_ ❑ Irrigation Y ❑ Industry/Commercial i i i i � ❑ Noncommunity PWS ❑ Remedial yy E T � � ❑ Environ.Bore Hole ❑ Dewatering ❑ i i i i ,� i i i r +2IM1e � CASING Drive Shoe? Yes ❑ No HOLE DIAM. _i _i_ _L_ _i_ I ';� �+Steel pl(Threaded ❑ Welded i i i i 1 ;�� kl ❑ P�astic ❑ s '' ) `�. �—t Mna—� 6 CASINtG DIAMETER �y WEIGHT ` PROPERTY OWNER'S NAME ' �i in.to 217 ft. 1 I _ Ibs./ft. 7 7�(ty �. 8 . �y . _ m.to ft. Ibslft. in.to n. Property owner's mailing address if fferent than well location a ress indicated above. --�--. _ in.to____ft. _ _____Ibs./ft. in.to ft. 2245 French Lake AQ SCREEN�RSQn OPEN HOLE Make from ft.to ft. � Wapzata, �iN 55391 Type stainless atee Diam. SIoVGauze__.__._____Tn� � Length�� ♦�+� Set between _____._�_}j3_ft.and�_�_ft. FITTWGS: « ST I WATER LEVEL n WELL OWNER'S NAME �� ___ _h.�below ❑ above land surface Date measured ��1 7� 0 PUMPING LEVEL(below land surtace) Well owner's mailing address if different than property owner's atldress indicated above. _°�8_3___ ft. atter� __hrs.pumping�g.p.m. WELL HEAD COMPLETION `��,,�♦w�� �Pitlessadaptermanufacturer�i�iy,_C�$ter Model ❑ Casing Protection �j r 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Wellgrouted? f�YYes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite MATERIAL from to_ ft. ❑ yds.�bags �— �� from to__._ ft. ❑ yds. ❑ bags � fillJwood black aoft 0 30 from �o n o Yds. o bags NEAREST KNOWN SOURCE OF CONTAMINAT ON �� clay/silt gr8 $Oft �Q 1,40 �.�' �eet �_____direction `�J.-�`-''--� rype Well disinfected upon completion? QT Yes ❑ No boulders/sand black hard 140 150 PUMP ❑ Not installed Date installed. 7+�+�_ mudd eg8�d ra ��l t �5� L1�7 Manufacturer's name ��rffiQ�s��_---- Modelnumber__ . __..,____.__. HP 3/4Volts L3ll �' w� p r > sand coiored S�f� 616 220 Length of drop pipe_ �Z_ _ _ __ ft Capaciry g.p m. Type:y�Submersible C LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed wel�(s)? ❑ Yes �No VARIANCE Was a variance granted from the MDH for this well? Ji�'Yes ❑ No TN# --�!� WELL CONTRACTOR CERTIFICATION �"' Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The information conlained in this report is true to the best of my knowledge. on _Stodole Well Drillin Co., I��c. __� 172` Licensee usiness me Lic.or Reg.No. _ 7-2�-nn horize epr tive Signalure Date Dnane Mathevs 6-19-flQ , _ _---- - __ 6 4 9 212 Name ol Driller Date LOCAL COPY HE-01205-07(Rev.2/99)