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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 688985 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 07 % 347 n 5-28-03 <br /> GPS DRILLING METHOD <br /> Latitude dNpWegrees minutes seconds _ <br /> L ail Logrees minutes seconds ❑Cable Tool El <br /> Dug <br /> ❑Auger >Fiotary Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ <br /> 4753 It Shore Dr, Orono 5536 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Shop exact location of well in section grid with"X". Sketch map of well cation. water FROM ft.TO ft. <br /> Showing prope y lines, <br /> N roads and t jildings USE ❑Monitoring ❑Heating/Cooling <br /> Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Noncommunity PWS ❑Irrigation ❑Remedial <br /> ❑Community PWS ❑Dewatering F-1 CASING vt HOLE DAM. <br /> w E t• [ Dn a Shoe? ,files ❑No <br /> T Threaded ❑Welded <br /> ��e(J. Steel <br /> ❑Plastic ❑ <br /> '/s Mile <br /> --- ----'------- I CASING DIAMETER WEIGHT <br /> S l \\ <br /> F1 Mile ,!f/ _ T� <br /> PROPERTY OWNER'S NAME/COMPANY NAME V ` in.to ft. IbsAt. 3U&to <br /> Bob Pieper SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make FROM 33Sft TO-41147—ft. <br /> same as above Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIICC©TER LEVEL <br /> 7 ftv,/below ]above land surface Date measured 5-28--03 <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> 210 ft.after hrs.pumping 40 g.p.m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer Vbj tgInSt Model <br /> ❑Casing Protection �12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted XYes ❑No <br /> Grout material ❑Neat cement ❑Bentonite ❑Concret.XHigh Solids Bentonite <br /> from 0 to ft. _ 10 ❑yds. Bags <br /> from to 8 ft. n& + l❑ft Irags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. ❑bags <br /> MATERIAL <br /> 7 NEAREST KNOWN SOURCE OF CONTAMINATION <br /> fill <br /> brown soft A t �- feet /fj direction typa <br /> V �! Well disinfected upon completion Yes ❑No <br /> clay yellow soft 4 38 PUMP �/� j_ <br /> ❑Not installed Date installed 9-29-0Ae <br /> 3 motor <br /> clay gray soft 38 70 Manufacturer's name <br /> /� <br /> Model number HPI Volts 230 <br /> clay/sand g ray soft 70 134 Length of drop pipe 126 ft. Capacity _ g.p.m. <br /> Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> clay gray soft 134 234 ABAADONEDWELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes 0W. <br /> fine sand gray soft 4 320 VARIANCE <br /> g 9 Was a variance granted from the MDH for this well? Yes E:]No TN# x.15 <br /> clay/gravel gray soft 320 338 WELL CONTRACTOR CERTIFICATION <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 /> limestone Use asecobVaX0e,ded hard 338 347 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Ikon Stodola Well- 11K 111.0. - 1ne � 72 <br /> Licensee Business Name 1c. r Reg.No. <br /> ;ul d e e nlh &qn.&,�r, <br /> Chuck_ Moore 5-28-03-___ <br /> LOCAL COPY <br /> � 688985 Name of Driller Date <br /> HE-01205-OB(Rev.5/02) <br /> IC 140-0020 <br />