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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> I.LOCATION OF WELL I MINNESOTA UNIQUE WELL NO. <br /> County Name WATER WELL RECORD 478365 <br /> Minnesota Statutes 156A.01-.08 for Wafer Sample <br /> Township Name Hennepin <br /> Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> O 118N °s` 23W w 33 SE ICE SE''' 167, 05/14/91 <br /> NumericalStreet <br /> yAdddretss7�an'd7Cittyy-oftWell Location or Distance from <br /> �Road <br /> ,Intersection. 5.DRILLING METHOD <br /> 225 Not. h Willow Drive Long Lake, MN 55356 0 Cable•fool ❑Reverse ❑Driven ❑Dug <br /> Show exact location of well in section grid with"X.•' Sketch map of well location. 0 Hollow Rod 0 Air ❑Bored ❑ <br /> N <br /> t i Addition Name [Rotary ❑Jelled ❑Power Auger <br /> "_r--7- -1--1-I I 6.DRILLING FLUID <br /> I <br /> H • I Water <br /> t I I Block Number <br /> -+- - - -- - 7. USE <br /> IN I i I • E <br /> ' i ' XDomestic 0 Monitoring ❑Heat Pump <br /> ILot Number 0 Irrigation 0 Public 0 Industry <br /> f•mi. 0 Test Well Cl Municipal 0 Commercial <br /> --1- _,_ - 1 <br /> --r- I ❑Air Conditioning ❑ <br /> � <br /> I--1 mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different thanpropertyaddress 0 Black 0 Threaded HEIGHT:Above/Below <br /> Jim Dittman indicated above. Surface ft. <br /> 0 GaIv. 0 Welded <br /> Drive Shoe? Yes_No— <br /> A Plastic R <br /> 4 in.to 162 ft. Weight 1.99 lbs./ft. min. to]67ft. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. ._in. to_ft. - <br /> FORMATION <br /> • in.to ft. Weight lbs./ft. Win. to_ft. <br /> moil Black 0 2 9.SCREEN Or'open hole • - • <br /> �t <br /> Make 4.-ilia—tel <br /> Japoo , from ft.to. ft. <br /> Clay Yellow 2 18 Type' PVC Dtam.4 ]11. t�?l. <br /> Slot/Gauze 15 blot Length 5 ft- <br /> Clay Blue 18 37 Set between 162 ft.and 167 ft. FITTINGS: <br /> MM, Blue icier yLg7'ER LEVEL 3x4 K packer <br /> CIVGi .raan 37 62 (Jjj f�- ft.N below ❑above Date Measured 05/1_4/91 <br /> land surface <br /> 11.PUMPING LEVEL(below land surface) 40 <br /> Clay Blue 62 67 ft.after hrs.pumping g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> Gravel Brawn 67 72 12.HEAD WELL COMPLETION <br /> ����` <br /> XPitless adapter manufacturer Maass Model <br /> Clay Blue }Maki 72 112 '❑Ba stir ,offset ❑At least 12• above ground <br /> •G <br /> 0 Plastic casing protection <br /> _ 13.WELL GROUTED? M Yes ❑No <br /> Clay-Sandi Blue 112 138 . <br /> Neat Cement 0 Bentonite ❑ <br /> Clay Blue }'ckir 138 150 0Grout material from to 30 ft.cu.yds. <br /> araW-21 -131igslack • 1 167 <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? *Yes ❑No <br /> 15. PUMP �y <br /> Date installed Tc/16/91 ❑Not installed <br /> gI 's name t'ae1746111�x <br /> 1 oORONO Model fi HP 3/4 Volts 230 <br /> fid pipe 140 ft. Capacity 12 g.p.m. <br /> / 1" PE <br /> a e a rop pipe <br /> Type: (Submersible ❑L.S.Turbine 0 Reciprocating <br /> ❑Jet ❑Centrifugal ❑ <br /> JUL 1. <br /> 1tQ�(p�116. ABANDONED WELLS <br /> 1nsi well on property? B Yes 0 No <br /> Use a second sheet,if needed Sealed R Permanent ❑ Temporary 0 Not sealed <br /> 17.REMARKS,ELEVATION,SOURCE OF DATA•etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> Stern- Well --)rill i ncs .n., The_ 27194 <br /> Licensee Business Name License No. <br /> Addres4240�Hwy 12 fe„../Mapt Plain, NI55159 <br /> Signed 1 `�J-'°'N�"L�-�-^e •-�'� Date 05/14/91 <br /> Authorized Representative <br /> mike Rivers DateO5/14/91 <br /> Name of Driller <br /> 1478365 5/74 <br /> 7/766NW <br /> LOCAL COPYE-01205-03(Rev.9/88) 2/8210M <br /> H <br />