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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 5 7 2 71 �. <br /> Hennep i n Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orona 117 23 7 ,NW,, SE,,. 200 " 9/�/95 • <br /> House Number,Street Name,City and Zip Code of Well Location or Fire Number DRILLING METHUD <br /> 1390 Park Dr�ve ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �Rotary ❑ Jetted <br /> ' Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> 4 � <br /> / Showing property lines, <br /> � roadsandbuildings. DRILLINGFLUID ���tOnit� - <br /> N <br /> I I I 1 <br /> _I_ ___ ___ _' <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i �Domestic <br /> _i_ _a_ _i_ _i_ "'"'"'�'�"""""�""� ❑ Irrigation O Community PWS ❑ Industry/Commercial <br /> i i i i : ❑ Noncommunity PWS ❑ Remedial <br /> w ' f f E� j t ❑ TestWell ❑ Dewatering ❑ <br /> t <br /> i -, i i �/ZM�a t'f-�""""-"", CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ i_ _L_ _i_ � � ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> �Plastic ❑ <br /> s <br /> �1 Mile� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 195h 200 Ibs./ft. $ in.to 64t. <br /> Wayne Holmes ,�.,o h. �bs.�n. ���.to�. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make +r 3.] C�_� from ft.to ft. <br /> Type ��vt� Diam. <br /> SIoUGauze Length <br /> Setbetween � ft.and ft. FITTINGS: aCke� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 7 d itKE] below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. � ?O ft. after 3 hrs.pumping 4 o g.p.m. <br /> �ELLHEADCOMPLETION �itewater .S—rJ�� <br /> Pitless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> _ ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? � Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement �Bentonite ❑ Concrete ❑ igh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from 6� to 6 ft. � ❑ yds. �bags <br /> (�'1.�I7 f f 11 brown SC�f t � 3 from to ft. ❑ yds. ❑ bags <br /> from [o ft. ❑ yds. ❑ bags <br /> tL) SO�1 black j�Q(�� NEARESTKNOWNSOURCEOFCONTAMINATION <br /> p 3 4 4� feet � direction g���r ���i'�e' <br /> Well disinfected upon completion? C�Yes ❑ No a f Y' teStE,.s('� <br /> G'Z�Y broWn ���• `� 27 PUMP <br /> ❑ Notinstalled Dateinstalled ��g�96 <br /> clay bIL1G H1Ga. �7 �4 Manufacturer'sname Sta"'Rit@ <br /> Model number S l 00M HP I voics <br /> san:� brown f i ne 6� ��1 Length of drop pipe 1 ft. Capacity 1 5 g.p.m. <br /> ' Pressure Tank Capacity <br /> sand & gravel brown i8� 2d� Type: f�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes C�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes L?�o <br /> WELL CONTFiACTOR 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 /> R.E.S. Weii Driliing 2?276 <br /> oA� A k`,T , Licensee Business Name Lic.or Reg.No. <br /> V 't W { <br /> :�� � t�-� ��.�: (--- ������ <br /> �, �_� -, <br /> Authonzed Representat�ve S�gnature Dafe <br /> Robert E. Stodola, Jr. 9/9/96 <br /> Name olDriller HE 01205-OS(Rev.1/95) <br /> LOCAL COPY � 7�7 i 1 <br />