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1 14 <br /> 4L TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 5 3 615 6 <br /> HeilileP119 Minnesota Statutes Chapter 1031 <br /> Township Name Township No. • Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> Orono 117 23 09 V. 1uU' 11-30-93 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> (`�,,. <br /> El Cable Tool 0 Driven 0 Dug <br /> 1000 Old CrWed OC <br /> ystal Bay N Orono, Ivr.. 0 Auger L (fotary 0 Jetted <br /> Sho exact lobation of well in section grid with"X". nn Sketch map of well location. ❑ <br /> // v Showing property lines, <br /> N roads and buildings./. DRILLING FLUID <br /> r <br /> t i ,� dr <br /> ,USE ❑1�omestic DI Monitoring ❑ Heating/Cooling <br /> + - . _ 1- ❑ Industry/Commercial <br /> Mite <br /> yy i ; I E� ❑ Irrigation ❑ Public <br /> __1_-_i_ __ ___ ❑ Test Well OD O Remedial <br /> I f mi. <br /> O CASING Drive Shoe? ❑ Yes ❑Vo HOLE DIAM. <br /> --;- - - ---r- I V ❑steel 0 Breaded ❑ Welded <br /> 1-----,„,,,___, O ❑ Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME Lake A roc au'j nuc.; 4 in.to 104. lbs./ft. 2 ih,to_;'.ft, <br /> in.to ft. lbs./ft. _1ty.to r ft. <br /> Mailing address if different than property address indicated above. tti� in.to ft. lbs./ft. in.to ft. <br /> 1 212 East Wayzata Blvd SCREEN OPEN HOLE <br /> Wayzata t MN. 55391 Make S,Johnson from ft.to ft. <br /> '"-,'.yP 3 Type S 11.t lPs step Diam. 41.n <br /> Slot/Gauze }�"�(i f� Length 4 r <br /> Set between I tl4 ft.and 108 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO4li I i <br /> MATERIAL ft. ❑$slow ❑ above land surface Date measured 11-30-93 <br /> PUMPING LEVEL(below land surface) <br /> Clay 0 t 9{)' ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> Sand 90' 1 U ❑Xitless adapter manufacturer WhitPWa t`er Model <br /> ❑ Casing Protection ❑12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? ❑ y s 0 No <br /> Grout Material ❑ Neat cement ❑ pentonite <br /> from ' to t/ ft. 0 yds. 0 (¢egs <br /> from to ft. 0 yds. ❑ bags <br /> from to ft. 0 yds. D bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? ❑Xes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed ��cLr�r, �•.�,..�1-18-94� &2-"94 <br /> Manufacturer's name 2RP �dixAfC <br /> Model number 63' HP me Vol2 f 210 <br /> RECEIVED <br /> Length of drop pipe t ft. Capacity g.p.m. <br /> Pressure Tank Capacity 120 Gallon Galv. <br /> APR 1 4 1994 Type: ❑submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> � <br /> ABANDONED WELLS <br /> CI■ Y�/OF ORONCI Does property have any not in use and not sealed well(s)? ❑ Yes ❑klo <br /> 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 /> Use a second sheet,it needed <br /> DON S WELL DRILLING CO+♦ INC• 27172 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> 11-30-94 <br /> 'utho zed'-presentatiie Signa ur Date <br /> F.P. McMahan 11-30-94 <br /> Name of Driller Date <br /> LOCAL COPY 53615 6 HE-01205-04(Rev.5/92) <br />