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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Bennepin Minnesota Statutes Chapter 1031 <br /> 643190 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) • Date Work Completed <br /> Orono 117 23 02 185' 8-1-00 <br /> v. <br /> House Number,Street Name,City, <br /> City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 15 Orme Orcrdd Orono, .55391 0 Cable Tool 0 Driven ❑ Dug <br /> 0 Auger _ 2 Rotary 0 Jetted <br /> Show exact location of well in section grid with"X'. Sketch owinngg map of well lo ' 0 <br /> Sh <br /> roads and bu DRILLING FLUID WELL HYDROFRACTURED? DYES <br /> NO <br /> N j � <br /> - --i" i --- i �ep>•+1 <br /> FROM ftto ft. <br /> i I USE X 0 Monitoring 0 Heating/Cooling <br /> L---`- Domestic 0 Community PWS 0 Industry/Commercial <br /> O Irrigation <br /> W i i E ❑ Environ.Bore Hole -0 Noncommunity PWS 0 Remedial <br /> i i T - ❑ Dewatering ❑ <br /> --r--ti---r---r- <br /> i 1 ,ham • telt <br /> "- CASING Drive Shoe? j Yes 0 No HOLE DIAM. <br /> j I O, X Steel jig Threaded 0 Welded <br /> 0 Plastic 0 <br /> S <br /> —,mii,,_I • <br /> re) CASING DIAMETER WEIGHT <br /> _ <br /> PROPERTY OWNER'S NAME •*.�,����, �si� Inc4 in.to 169 tt. 11 Ibs./ft. 7 7-n _Q. <br /> /i��its roup Inin.to ft lbs./ft.lilt_in.tots*. <br /> Property owners mailing address if different than well locationoctiaddress indicated above. in.to N: 'befit. 3-4l11 <br /> 14151 <br /> 20303 Lakevisur allure SCREEN OPEN HOLE <br /> laior, I . 53331 Make link from 9 tt.to_ ft. <br /> Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 50 ft.igbelow 0 above land surface Date measured 1111-1-00 1 <br /> PUMPING LEVEL(below land aUrface)+� <br /> Well"owners mailing address if different than property owners address indicated above. 165 ft. after 23 hrs.pumping 30 g.p.m. <br /> WELL HEAD COMPLETION �yy,,g <br /> • O Pitless adapter manufacturer wuzit.*.ratter Model✓Inc - - <br /> 0 Casing Protection 12 in.above grade <br /> 0 At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ip Yes ❑ No <br /> HARDNESS OF Grout Material 0 Neat cement- High Solids Bentoni)e <br /> GEOLOGICAL MATERIALS COLOR FROM TO 0 Bentonite 0 Concre 0 <br /> MATERIAL' <br /> from_to 30 ft. 21 0 yds."; bags <br /> from to_Amt. atitteria 0 yds.0 bags <br /> Clay _ Yellow 9 a" 10, from to ft 0 yds.0 bags <br /> 8 NEAUFA�T KNOWN SOURCE OF CONTAMINATION <br /> Clay/Gravel Gray1 d' 1 , 13 feet north direction sept l <br /> e type <br /> ar y� <br /> K O Well disinfected upon completion? lig Yes 0 No <br /> Sandstone 9ro�Gira2 160'1*51 PUMP <br /> 0 Not installed Date installed 1 11 6I <br /> Manufacturers name !! <br /> Model number HP 1 a 5- Volts 230 <br /> Length of drop pipe 84 ft. Capacity g.p.m.• <br /> Type:XSubmersible ❑ LS.Turbine 0 Reciprocating 0 Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes MgNo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes SW TNM <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 STODOLi1 WELL DULLING CO., INC. <br /> Licen Business meLic.or Reg.Na <br /> '�--' - 27172 <br /> 12-5.-00 <br /> Autho ed Represtl Ve Signature Date <br /> Doane PUltheirs 8- 1-00 <br /> Name of Driller Date <br /> LOCAL COPY 643190 HE-111205-07(Rev.2/99) <br />