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r-�, __ �'-1 <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD �g 4 9� 3 <br /> �je�lllepi,jl Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 11� 23 08 ,. ,. ,, 107 JAN n� 24/97 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 1230 Sprnce Place �� cabie T°°i ��—^ ❑ ��„e� ❑ 0�9 <br /> f7 Auger �Rotary ❑ Jetted <br /> � Show exact bcation of well in section grid with"X". Sketch map of well location. I 1 <br /> Showing property 6nes, -- <br /> � roads and buildings. DRILLWG FLUID <br /> N Wstel <br /> _� � � �_ �-� � t,U�.l I <br /> ,- -,- -r- -, <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i �Domestic <br /> _�_ _�_ _�_ _�_ ❑ Community PWS ❑ Intlustry/Commercial <br /> i i � � ❑ Irngation ❑ Noncommuniry PWS ❑ Remedial <br /> W E ❑ Test Well <br /> i i i i T C7 Dewatering ❑ <br /> _r _�_ _r_ 'r I �,,,,��. <br /> � i i i ��zM�e CASING Drive ShoC? ❑ Yes (�No HOLE DIAM. <br /> _i_ _i_ _L_ _i_ ❑ Steel ❑ Threaded ❑ Welded � <br /> i i i i t <br />_„ 1 � �Plastic a ���___ . __ <br /> S <br /> E---I M�le-� <br /> CASING DIAMETER WE�GHT <br /> PROPERTY OWNER'S NAME ___4 in.to 1�Z _ft. ___ _ Ibs./n. $ in.t�07 tt. <br /> � $tt b NanC HQe � in.to__fl. Ibs./ft. in.to ft. <br /> Property owner's mailing address if diflerent than well Iceation address indicated above. _—.— .in.to _ft. Ibs./ft. in.to tt. <br /> 10 �Tinnetka Av�. S• SCREEN_ p�C _ OPEN HOLE <br /> Gol�en Yallep, MN 55426 "'ake ��1-' from h�o tt. <br /> Type_Te1�BCOp AQ _oiam. <br /> SIoVGauze_ � Length g _ <br /> Set between� � ft.an—d I���—__n. FiTrw�s:_K-Packer <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 4,� ft. �elow ❑ above land surtace Date measured 1 1 Z4 7 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if ditterent than property owner's address indicated above. ,_ fl. afler_ ___ hrs.pumping 1�Q __g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑ Pitless adapter manufacWrer ___ Model . <br /> ❑ Casing Protection ___ ____ ❑ 12 In.above grade <br /> ❑ Abgrade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? � Ves � No <br /> HARDNESS OF Grout Material � Neat cement � eM i�� rl Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from � �_�ft. � ❑ yds.�bags <br /> from__to R. ❑ yds. ❑ bags <br /> Cli�j� j/l110Y 0 33 r�om _ co n. ❑ vas. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Cli� Qr�� 33 4Z _ feet __,_ direction rype <br /> Well disinfected upon completion? i.-1 Yes ❑ No <br /> SBAY St QraVe btOYII 41 lO7 PUMP ♦ <br /> ❑ Not installed Date instanee _ i�L�g��� <br /> Manufadurer's name �t^�_ _ <br /> Model number_ HP�_`_�__ Volts <br /> Length of drop pipe �� ft. Capacity �� g.p.m. <br /> Pressure 7ank Capaciry____�/ .p._ _ <br /> Type: ❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑ No nnknoxn <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? �7 Yes ❑ No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheeG i/needed This well was drilled under my supervision and in accordance with Minnesota Fules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Stevens Drilling � Eavironmental 8� <br /> � _ Licensee Business Name Lic.or Reg.No. <br /> ; : 12/16/97 <br /> Authonzed Representative Signature Date <br /> Panl Sxearinqen <br /> 5 9 4 9 0 3 Name ol Driller Date <br /> LOCAL COPY HE-01205-05(Rev.1/95) <br />