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WELL L OC1kTION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name Hennepin WELL AND BORING RECORD 573591 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 09 104' <br /> 2-21-96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 890 Old Crystal Bay Road Long Lake, Mn. 0 Cable Tool 0 Driven 0 Dug <br /> ❑ Auger S Rotary 0 Jetted <br /> Show exact location of well in section grid with"X". r.�e: Sketch map of well location. 0 <br /> �JJ 6 Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N , Bentonite <br /> {N,_`L L USE 0 Monitoring ❑ Heating/Cooling <br /> 4 i, �f lDomestic ty 0 Industry/Commercial <br /> ❑ Irrigation ❑ Communi PWS <br /> w I E ❑ Test Well ❑ Noncommunity PWS ❑ Remedial <br /> ❑ Dewatering ❑ <br /> 1 T- r <br /> /ZMae CASING Drive Shoe? 0 Yes 0 No HOLE DIAM. <br /> L <br /> El Steel 0 Threaded 0 Welded <br /> [](Plastic ❑ <br /> IS <br /> �,Me� /� SiP <br /> _ �} (� CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME <br /> 0 in.to 100 ft. lbs./ft. 7 718 30 <br /> Lake iat£s in.to ft. lbs./ft. 61/4 in.to_1_0t4 <br /> Property owners mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> 1212 FastWclyZata Blvd. SCRETEEN OPEN HOLE <br /> MakedOhnSOn from ft.to ft. <br /> Wayzata, Mn. 55391 TypeV/lr Diam.ZR <br /> Slot/Gauze 10/10 Length 4' <br /> Set between 100 ft.and 104 ft. FITTINGS: 20x2.5 <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 40 ft. is below 0 above land surface Date measured 2-21-96 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION M.t ter <br /> X Pitless adapter manufacturer Model <br /> ❑ Casing Protection X 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ®Yes 0 No <br /> HARDNESS OF Grout Material 0 Neat ce ent 0 Bento 't 0 Concrete High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> 1,� 9 <br /> from to ft. 77 0 yds. 0 bags <br /> from to ft. 0 yds. 0 bags <br /> Clay Gray soft 0 90 from to ft. ❑ yds. ❑ bags <br /> NEAR OWN SOURCE OF CONTAMINATION <br /> Water sand Tan media 90 104 feet 4Tia,t7TP direction SES/C-type <br /> Well disinfected upon completion? *Yes 0 No <br /> PUMP 3-26-96 <br /> ❑ Not installed Date instIlei d � <br /> Manufacturers name <br /> Model number 18LS1,`�— 4121► HP 1"L <br /> i Volts 230 <br /> Length of drop pipe 63' n Capacity 18 g,p.m. <br /> Pressure Tank Capacity #250 X-Troi <br /> Type: lXSubmersible 0 L.S.Turbine 0 Reciprocating 0 Jet El <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes 4010 <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes )ISS No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 S?ODOLI WELL DRILLING OD., INC:. 27172 <br /> Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Chuck More <br /> 5 � ` ��� Name of Driller Date <br /> LOCAL COPY J� HE-01205-05(Rev.1/95) <br />