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1 <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 68897 -1 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 11? 23 07 ,, ,A 246 � 6-3-0 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑I Cable Tool L]Driven ❑Dug <br /> ❑AugerS�Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ / <br /> 4535 It Shore Dc Orono 5536 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes XNo <br /> Shop exact location of well in section grid with"X". Sketch map of well location. benoonite FROM ft.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE ❑Monitoring ❑Heating/Cooling <br /> Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Noncommunity PWS ❑irrigation ❑Remedial <br /> Community PWS ❑Dewatering <br /> 7� ❑Comm ❑ <br /> CASING Yes )(No <br /> HOLE DIAM. <br /> W � � � E T Drive Shoe? <br /> e ❑Steel ❑Threaded ❑Welded <br /> $Mile Plastic El <br /> CASING DIAMETER WEIGHT <br /> S Ni t _ A in.to_218 ft. ?.()I lbs./ft. in.to_34ft. <br /> -1 Mile-� �.; +\_1� it, <br /> in.to ft. lbs./ft. in.teff. <br /> PROPERTY OWNER'S NAME/COMPANY NAME * in.to ft. lbs./ft. in.to ft. <br /> Tonevood Deei Build SCREEY OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make_-" 0 FROM ft. TO ft. <br /> 4420 Shoreline Dr Type Diam. <br /> Spring Park, MN 55384 Slot/Gauze •010 Length 49 * 41 <br /> Set betweenft.and ft. FITTINGS <br /> STATIC WATER LEVEL ] <br /> 65 ft. 6 <br /> below ❑above land surface Date measured 6-3-03 <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME 235 <br /> ft.after 1.5 hrs.pumping40 __g p.m. <br /> WELL HEAD COMPLETION �2 <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer waif tealltlr Model _ <br /> ❑Casing Protection >f12 in.above grade <br /> IR=CSVEp ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION�j <br /> Well grouted !�'-- Yes ❑No <br /> 6 2004 Grout material ❑Neat cement ❑Bentonite ❑Concrete High Solids Bentonite <br /> g"_ from .to_5ft. 3 ❑yds. )<bags <br /> 'YOv. -�'from 0 t-238 ftnat,r� f fj}❑bags <br /> GEOLOGICAL MATERIALS <br /> YL <br /> HARDNESS OF FROM TO from to ft. ❑yds. ❑bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet <br /> �" direction pe <br /> topsoil black soft 0 3 d -1 =�- ty <br /> Well disinfected upon completion 9Yes ❑No <br /> clay brown soft 3 181 <br /> PUMP 6-22-03 <br /> '❑Not installed Date installed_ <br /> clay ra soft 18 84 Manufacturer's name AervDtor <br /> Model number HP 105 Volts Zia <br /> *and gray Soft 80 110 Length of drop pipe NQS ft. Capacity g.p.m. <br /> Type:, Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> clay/sand Rray Soft 10 230 ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) _.Yes XNo <br /> Ater sand t C8 soft <br /> 4 <br /> 0 2fL VARIANCE <br /> 1 't Was a variance granted from the MDH for this well? 7 YesNo TN# <br /> WELL CONTRACTOR CERTIFICATION rX <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed Drilling <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Son Stodola Well Drilling Co., Inc. 27, 72 <br /> Licensee Business 00ame _- Lic.or Reg.No. <br /> uthoriz presentative Signature- Date <br /> Chuck Moore---6-3-03-- <br /> Name <br /> o Ire -_-3-03__ <br /> 9 7. Name of Driller Date <br /> LOCAL COPY HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />