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} <br /> MINNESOTA UNIQUE WELL <br /> WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD <br /> Hennepin Minnesota Statutes,Chapter 1031 743401 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 23 I 03 ft. <br /> GPS DRILLING METHOD <br /> L1 Cable Tool Ll Driven El Dug <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees_ minutes seconds_ ❑Auger XAotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number LI <br /> 450 Willow Dr $ Orcxw 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Show exact location of well/boring in section grid wit "X." Sketch map of well location. Nater From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings, USE omestic 1-1Monitoring 11Heating/Cooling <br /> Iand direction. ❑Noncommunity PWS EJ Environ.Bore Hole 11Industry/Commercial <br /> " ?------'------- t 1 a ❑Community PWS ❑Irrigation ❑Remedial <br /> ❑Elevator ❑Dewatering ❑ <br /> CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM. <br /> W E <br /> ❑St eel ❑Threaded 11Welded <br /> , <br /> lactic 11 <br /> /z Mile <br /> CASING <br /> I t Diater 116 Weight_ _ Specifications's <br /> S '2 aster <br /> �1 Mile� \ f <br /> in.to ft. Ibs.ttt. in.t 30 ft. <br /> in.to ft. lbs./ft. in.t ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> Smn Valentine SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make From sl"ft.To ft. <br /> 12600 OrchardRd Type stainless stl Diam. 2 <br /> _ <br /> Nim*tomka� � 55305 Slot/Gauze _020 Length 60 ;fit <br /> rLL VIiR�II .rill Set between ft.and ft. FITTINGS - <br /> STATIC WATER LEVELL�/ <br /> ft.Xelow ❑Above land surface Date measured 9-7 <br /> PUMPING LEVEL(below land surface) <br /> WELL/BORING OWNER'S NAME/COMPANY NAME 114ft.after 2 hrs.pumping 30 g.p.m. <br /> W LL HEAD COMPLETION <br /> Well/boring owner's mailing address if different than property owner's address indicated above. OrVitless Adapter Manufacturerel <br /> El Casing Protection 2 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? P(Yes ❑No <br /> Grout materials ;--1 Neat cement Bentonite El Concrete ❑Other <br /> From -0 To30� ft. 3 ❑Yds. ❑Bads <br /> -From_�__To i�46 ft.�—fjlli ElBags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF <br /> MATERIAL FROM TO - From To ft. LlYds. 17 Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION �,ry feet direction m,». '!*" —tyl- <br /> topwil black <br /> Well disinfected upon completion? es ❑No <br /> PUMP <br /> cls ❑Not installed Date installed {� <br /> said gmy soft 93 12A <br /> Manufacturer's name <br /> Model Number HP + Volts <br /> Length of drop pipe ft. Capacity 9.p-m. <br /> Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑YesJo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,i/needed. � � <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. r 7f�`.a&1s � 11Dri1ling Co.. Im. <br /> Licensee Business Name ,.� "O Lic..or Reg.No. <br /> Iv2- G 0(0 <br /> A horized Representative ;gnature Date <br /> Chwk Mom <br /> LOCAL COPY 743401 <br /> A 3 4 n Name of Driller <br /> '+ t,.! HE-01205-09(Rev.9/05) <br /> IC 140-0020 <br />