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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 68657 :5::] <br /> H Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) itDate Work Completed <br /> 8 1-7-03 Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 70 N Shore Dr W. Orono, 55359 ❑ Auger L otary ❑ Jetted <br /> Show exact location of well in section grid with'X". Sketch map of well location. ❑ ,` <br /> Showing roperty lines, <br /> roa rrd buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES f(NO <br /> N , <br /> bentonite .FROM—ft.to ft. <br /> USE [IMonitoring ❑ Heating/Cooling <br /> Domestic ❑ CommunityPWS <br /> 1-1 Irrigation ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> W 1 i i E ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> -r CASING Drive Shoe? ❑ Yes KNo HOLE DIAM. <br /> zMoe <br /> L- ,- I ❑ Steel ❑ Threaded ❑ Welded <br /> i -i- i i 1 <br /> �"Plastic ❑ <br /> s <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAMEIS in.to I Qa ft. 2 0 lbs./ft. 8.—in.to-30 ft. <br /> in.to ft. lbs./ft. in.10498 <br /> Property own(7's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> 16913 Excelsior Blvd SCREEN OPEN HOLE <br /> Make Johnson from ft.to ft. <br /> Minnetonka, MN 55345 Type Stainissgtj Diam. 2" <br /> Slot/Gauze Ain Length <br /> Set between ft.and ft. FITTINGS: <br /> 9"W113" MAD <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 94 _ft.Kbelow, ❑ above land surface Date measured_1-7-03 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 1 ft. after 2 hrs.pumping 45 g.p.m. <br /> WELL HEAD COMPLETION obite�Tater <br /> ? Pitless adapter manufacturer Model <br /> ❑ Casing Protection L➢It2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) /` <br /> GROUTING INFORMATION <br /> Well grouted? )1(Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ElConcrete High Solids Bentonite <br /> MATERIAL from to— 30 ft. —3 ❑ yds. Ybags <br /> from to_1.90 ft. natural Hyt 11 bags <br /> clay yellow soft 0 3 from to ft. ❑ yds. ❑ bags <br /> ^ NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay gray soft 30 9 T--) —feet _ direction type <br /> Well disinfected upon completion? Wyes 1:1 No <br /> clay/sand gray medium 90 12 PUMP T <br /> ❑ Not installed Date installed - ,.,!9 03 <br /> gravel brown medium 120 14q Manufacturer's name a mo_ <br /> Model number HP--,5 Volts 230 <br /> sand/gravel brown Soft 140 198 Length of drop pipe ''''rr� ft. Capacity g.p.m. <br /> Type: ('Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑ <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 o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,it needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Don c+F�..�..�=- ,,eseAXve_Sq4ffatuFe <br /> �?�.l nr-l=ines 27172 <br /> e. ame Lic.or eg. o. <br /> / 7-28-83 <br /> Date <br /> 7 NameofGrille ae <br /> � 68 <br /> LOCAL COPY �5 t 5 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />