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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL NO. F County Name WELL AND BORING RECORD , , , Hennep3n Minnesota Statutes, Chapter 1037 � � �� ¢ �� ; ,Township Name Township No. Range No. Section Nq. Fraction WELL DEPTH(completed) Date Work Completed �; ' Orono i1T 23 1�i ,� ,� �, n _ + -' GPS ` DRILLING METHOD � LOCATION: Latitude degrees minutes _ seconds Longitude degrees minutes seconds ❑Cable Tool r Driven Dug ❑Auger �'Flotary Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �-� 1 b�0 Bohns L"ZI�LIC �,d� Or000 5391 DRILLING F�UID WELL HYDROFRACTURED? ,_]Yes No S exact location of well in section grid with"X". Sketch map of well location. b�n t on i t e FROM ft.TO ft. Showing property lines, N roads and buildings USE ��Monitoring �Heating/Cooling ' � � � � �Domestic [_J Environ.Bore Hole �L�Industry/Commercial ' --'--- --'--- --`-----'-- . �Noncommunity PWS �.._'Irrigation ,_ �Remedial �Community PWS ��Dewatering ] ' --'----'-----`-----`-- � CASING HOLE DIAM. ' .� w ; ; ; � E T Drive Shoe? f..�Yes �No � - � . � _Steel ��Threaded [�Welded '/Mile ' Plastic ` ] 1 `�� CASING DIAMETER WEIGHT s �� 11 � 1 Mile� -�� L -� �——in.to�_�ft. 4 Ibs./k. __�in.to 9 f1ft. i �Q _ in.to ___, ft. _ Ibs./ft �in.to��t. � PROPERTY OWNER'S NAME/COMPANY NAME in.to_____ ft. Ibs./ft. in.to ft. - ' �n j v --�-- .__.._ .. Robert �rC�i� 1'!OR}EB SCREEN OPENHOLE � f ., Property owner's mailing address it different than well location address indicated above. Make JO�TISOII FROM fL TO ft. � 565 Big Waoda �� Type fdtg�tf1�R14 �tI, Diam - ` Chanha�sen, t�fAi 55327 SIoUGauze ____*�'1� Length __��_ �_ ___._ Set between ft.and ft. FITTINGS 1� � STATIC WATER LEVEL ' �3 ft.'�below �above land surface Date measure��3�Q6 PUMPING LEVEL(below land surface) WELL OWNER'S NAME/COMPANY NAME I g� �� hrs.pumping �O ' ft.after 9.p.m. WELL HEAD COMPLETION �{� �. Well owner's mailing address if different than property owners address indicated above. �pitless adapter manufacturer �..J-�T�a,.7�.s-�.�s7�el _'Casing Protection �12 in.above grade . At-grade(Environmental Wells and Boring ONLY) � GROUTING INFORMATION - Well grouted �Yes _.]No Grout material ❑Neat cement I,__j Bentonite ❑Concrete�High Solids Bentonite _ from � to____! ��ft. 3 _yds. �bags from 3� to l��ft. �a't$ra��y�si��ags HARDNESS OF GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from to ft �yds. �,J bags NEAREST KNOWN SOURCE OF CONTAMINATION . C�I�y b ro�n .g(�f� ll �V `1.-r feet /`✓ direction . ��-fi��_�+�:^}ype Well disinfected upon completion Yes ��-No ��-.. "'+Jc..c��---� ��... G18� �r8y soft '�� PUMP [ Not installed Date installed �' •:.J'`� �--�� � L ,�:-�.�,s�.� sand g�$� .�(�f t �,v I�iQ Manufacturer's name �^.�.,, -._ � Modelnumber � HP�Volts =�� Length of drop pipe �� ft. Capacity_ g.p.m. Type:[�Submersible ❑LS.Turbine ❑Reciprocating ;_i Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s) ❑Yes No VARIANCE Was a variance granted from the MDH for this well? �]Yes No TNN WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. , Use a second sheet,if needed � ; REMARKS,ELEVATION,SOURCE OF DATA,etc. vV n S r odo i a �e Z 1 D r i 1 I in�; Cd� • 18�• G 1 7 Z�:,�. Licensee Business Name Lic.or Reg.No. � - �..�,�� J� uy _ed Repre entative Si t Date Chuck pivare �OCAL COPY �� l�ameof�riuer HE01205-OB(Rev.5/02) - C 140-0020