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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 648563 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. I Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 118 23 21 Sii,NR,,SW 166 n 7/26/00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 340 Turnhas Road Orono ❑ Auger Rotary ❑Jetted <br /> Show exact location of well in section grid with"X'. Sketch map of well location. ❑ I� <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? El /k YES 1NO <br /> N � <br /> Water FROM ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i Domestic ❑ CommunityPWS <br /> -1- -J- -�- -�- ♦ r Irrigation ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> w E � ) ` ❑ Environ.Bore Hole <br /> ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes 41,No HOLE DIAM. <br /> -i 1 -L- -i- t-•— •---'' ❑ Steel ❑ Threaded ❑ Welded <br /> Ll Plastic . <br /> s !` <br /> —1 Mile -i <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 161 ft. lbs./ft. 81 in.to45 ft. <br /> Eric Menge in.to ft. lbs./ft. If— <br /> in.tel6L6-ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to_ft. <br /> 360 Turnh" Road SCREEN OPEN HOLE <br /> Orono, MN 55323 Make J$VCQ from ft.to h. <br /> Type "C Diam. '3 <br /> Slot/Gauze 15Length 5I <br /> '`G <br /> Set between 161 ft.and 166 FITTINGS: Y�nnnlrnr <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 132 ft.�Q below ❑ above land surface Date measured Saine <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 20 g.p.m. <br /> WELL HEAD COMPLETION <br /> *Pitless adapter manufacturer Model 4" <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? lk Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement X Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from to ft. -3 ❑ yds.g bags <br /> Topsoil Black O 3 from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Clay Gray 3 56 feet direction none —type <br /> Well disinfected upon completion? X Yes ❑ No <br /> Cloy/gravel Gray 54 95 PUMP <br /> Gravel Mixed 95 160 ❑ Not installed Date installed $/3/00 <br /> Manufacturer's name Myers <br /> Sand Gray 140 166 Model number to HP 3/4 volts <br /> Length of drop pipe 140 ft. Capacity 12 _g.p.m. <br /> Type:IV Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes V No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes T No TN# <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 /> Li ensee Busines me14�Lic.or Reg.No. <br /> $/4/00 <br /> Authorized Represents a Signature / Date <br /> 16485631 a Date <br /> LOCAL COPY HE-01205-07(Rev.2J99) <br />