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_11i_ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD6 6 8 O O 2 <br /> Hennepin Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. I Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 118 23 1 36 y. 200 11- '8-Ol <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 360 Wakefield Rd Orono 5 391 El Cable Tool El Driven El Dug <br /> ❑ Auger Rotary ❑ Jetted <br /> Show exact location of well in section grid wit Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> N super 8411-s <br /> FROM ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> ❑ Domestic ❑ CommunityPWS <br /> -- - - -+- -- QNrrigation ❑ Industry/Commercial <br /> ❑ Noncommunity PWS 11 Remedial <br /> W i E ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> �/ZMile <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> XPlastic 171 <br /> s <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �+ in.to 292_ft. ad 21 lbs./ft. <br /> Wayne Le Neave in.to ft. _lbs./ft. in.to 10 0 <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> same as above SCREEN OPEN HOLE <br /> Make jr from fLto ft. <br /> Type stainless steel Diam. IV — — <br /> SloVGauzewoso Length_ 9 + <br /> Set betweenft.and ft. FITTINGS:- <br /> STATI�fy�1TER LEVEL e <br /> WELL OWNER'S NAME 77 ft. below ❑ above land surface Date measuredpn U— - v1 <br /> PUMPING LEVEL(below land surface) q t �f <br /> Well owner's mailing address if different than property owner's address indicated above. 180 ft. after 2 hrs.pumping 32 g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑ Pitless adapter manufacturer�--� Model <br /> ❑ Casing Protection �a�i wry sea ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INF RMATION <br /> Well grouted? XY.s ❑ No <br /> HARDNESS OF Grout Material ❑ Neat ce nt ❑ Bentonite EI Concrete High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from to 30 It. 3 ❑ yds. bags <br /> topsoil black soft ol from_30 to 192 ft. natal fjj(j.r bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEA OWN SOURCE OF CONTAMINATION_ SE T I type <br /> gravel gray soft 1 feet G<,/ES / direction <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> clay gray soft is 10PUMP <br /> LI Not installed Date installed 11-23-01 <br /> gravel/rocks colored medium 10 10 Manufacturers name A etuotor <br /> clay pray medium 105 161 <br /> Model number t HP_2 Volts 730 <br /> Length of drop pipe 105 ft. Capacity g.p.m. <br /> clay/gravel, gray soft 161 19 fdy <br /> Type: 1TSubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> sand gray soft 190 200 <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ,)<ho <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �4 TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/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 Stodola Well Drilling ea._ Inc_ -27172 <br /> Liceirsee.6usiness,Name 7Ic.00r Regi <br /> 12-6-)l <br /> Authorized Representative S' a urs Date <br /> Daane 'Nathevs 11-8-01 <br /> Name of Driller Date <br /> LOCAL COPY � 668002 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />