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I. LOCATMWTM <br />Cmunty Name <br />Hennepin <br />ESOTA DEPARTMENT OF HEALTH <br />WATER WELL RECORD MINNESOTA UNIQUE WELL NO 4 5 8 9 3 5 <br />Mranesaa Se.laks 156.4 01 bN /w Water Sa-Ne <br />mweship Name' ownahip Number <br />Rarter Number <br />Section No. <br />Fraction <br />1 WELL DEPTH tmmpMedi <br />late d CompkltrM <br />Orono - 111 <br />23 w <br />5 <br />NW '" NW " NE" <br />138 It <br />2-8-90 <br />_._-- S <br />Nurne " S Addres•. and City cf Well Idwation or Distartce from Road Interaction. <br />5 DRILLING METHOD <br />3485 Christine r . , Orono <br />❑ Cable loci O Rnersr ❑ Driven O Due <br />❑ Hollur Rod O Air ❑ Bond O —_ <br />-lion cd we 1 in se'ctton grid with <br />,x Sketch map of well InOtton <br />N <br />Addition Name <br />andary Olnted ❑ WWer Auger <br />L_ <br />•-r- t - , <br />6. DRILLING F1U!D <br />Bentonite <br />t <br />lock umber <br />- <br />7 USE <br />W t r t E <br />T <br />x1 Do ut O Monitoring ❑ Heal Pump <br />_1_ _ _ _- <br />1 ' <br />1<a Number <br />❑ Irng.! .o O Public ❑ Industry <br />y -t <br />O Test Well ❑ Municipal O Commercial <br />t <br />❑Au Condnwnmg ❑ <br />1 1 aak, <br />R CASING I <br />HEIGHT Above%Below <br />fxBlack � Threaded <br />HOLE DIAM <br />2. PROPERTY OWNER'S NAME Mallin Address if different than ro n addrevv <br />B P a ) <br />indicated above. <br />Surface It <br />Betz Builders 415 Deborah Ora <br />OGal, ❑Welded (hive Shoe' Yes_ No -K <br />Maple Plain, MN 55369 <br />❑ 19astic 4 El <br />124 Weight 11 Ibs ft <br />6_jm .138 <br />,n 10 It <br />___ in to It Weight Its; 11 <br />in to — 11 Weight Its /It <br />ten. Iu_Jt <br />- n. to_JI. <br />3. FORMATION LOG COLOR <br />HARDNESS OF FROM <br />FORMATION <br />TO <br />C l a,y Tan <br />Med 0 <br />p <br />28 1 <br />9 ,C RE Ur open 1.4,Make <br />Johnson from—"'° It <br />Clay Gray <br />Med 28 <br />103 <br />SS Main. 2" <br />Type _ — <br />Slut/Gattre -10.10.10 _ Length 16'" <br />FITT1 GS <br />— <br />Gravel <br />Soft 103 <br />106 <br />,et between 124_ It and 138 It <br />C1 �V <br />Gray <br />.7 <br />Med 106 <br />108 <br />10 ,9AW LEVEL 2-8-90 <br />It,YI below O -bone [hie Measured <br />SS0 __ft <br />la surface <br />Gravel138 <br />J9 <br />I I PUMPING I EVEL (below landsurface) <br />122 50 <br />r1 after _l1 his pumping -- spin <br />It after hrs. pumping . - - gip in <br />fff��� <br />_ <br />WELL COMPLETION <br />lless adapter manufacturer Wh i towatpr Modrl Ro 1 t on <br />Basement offset O At feast 12" above /round <br />Plastic casing pro(ection <br />r <br />` <br />13. WELLGROUTED' RYn O No <br />❑ Neat Cement O Brntonur ❑ drill cuttings <br />Grout material from to It Cu yds. <br />1: NEAREST SOURCESOF POSSIBLE CONTAMINATION <br />-I L. feet _SE__ direction S xr r -t)pe <br />-- <br />Well disinfected upon compklwo )Mft ❑ No <br />11 PITNP <br />9st,-Iii1led 2-21-9� ❑ No,rnatalled <br />Manufacturer's name—�►f{.YK+------ - - <br />Model number .I HS -41810 -SL HP—�- •. ,, s.2 an <br />/1 <br />Lengthofdropp. __110 ft Capacity ��g --epm <br />Material of drop pipe --__ — <br />Type Wubmerstbk rl L S Turbinr ❑ Reciprocating <br />__6 <br />01" ❑ Centrifugal a-- <br />6 Al A.NDONED WELL: <br />Unused well onpeoP"W O Y- A No <br />Use a seroad <br />sAeer. rl weeded <br />Y+W ❑ Permanent ❑ Temporary ❑ Not sealed <br />is WATER WELL CONTRACTOR CERTIFICATION <br />This well was drilled under my;unsdtctton and this report is true to the best of my <br />kno.kda and belief <br />_hark Seel 02133 <br />Addrn 7kTf§9t9 Ave NW, Anoka, MN' 55303 <br />Signedl-1= Datr / <br />Aurhontad N•prran•rvnnn <br />Ste e_Aeshliman _ 2-9-90 <br />.litme• r>I (7n14•r <br />HF -01205.034 Rn. 9188; <br />5174 30M <br />1176 76 30M <br />7/74 3MA <br />2/62 10M <br />