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! <br /> �� . <br /> .�.. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 5 719 0 <br /> Hennep i n Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Orono 117 23 2 SW,,,NTej SW,,, 2 28 10/31/O1 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DAILLING METHOD - <br /> 2120 F��{ �Jt'.. Orono, MN ❑ CableTool ❑ Driven ❑ Dug <br /> [7 Auger �Rotary � . ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well iocation. C7 ____.__.___ ____ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �NO <br /> " :;'-� Baroid uik el <br /> i � i � g FROM __ft.to fl. <br /> -� -i- -i- -i- '� <br /> �1J . � USE ❑ Monitoring ❑ Heating/Cooling <br /> � � i i .. . - �Domestic ❑ Communit PWS <br /> �npfff��� ❑ Irrigation Y ❑ Industry/Commercial <br /> i i i i � � ❑ Noncommunity PWS ❑ Remedial <br /> y,� E - ❑ Environ.Bore Hole <br /> i i i � ,�,���,� r ❑ Dewatering ❑ <br /> -i -�- -r- -r T ,' ���...."t..- <br /> i i i i ��2M.1e � -- CASING Drive Shoe? ❑ Yes C*No HOLE DIAM. <br /> _i i i i_ � , ❑ Steel ❑ Threaded ❑ Welded <br /> I I I I vj <br /> �Plastic ❑ <br /> s �,,. <br /> �1 Mile--� . <br /> � CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to �1�t. I�91bs./ft. 8�n.to 3d n. <br /> K1I/1Q HuDt in.to tt. Ibs./fl. ��n.toy�8. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to_ft. <br /> 18324 Minnetonka �lvd. SCREEN OPEN HOLE <br /> Deephaven, Pin 55391 Make cresl ne from n.to n. <br /> Type__�7 a�t�t'� Diam. _�p <br /> Slot/Gauze � ¢ Length <br /> Set between 1 8 ft and � 7 a tt. FITTINGS: � <br /> STATIC W��i LEVEL �[ 1 O 3� <br /> WELL OWNER'S NAME _ �� ft. L7�elow ❑ above land surface Date measured � <br /> PUMPING L EL(below land surface) <br /> Well owner's mailing address if ditterent than propeRy owner's address indicated above. � ft. after 1 hrs.pumping 40 g.p.m. <br /> WELL HEAD COMPLETION ����� i <br /> �Pitless adapter manufadurer R���11�ter Model S11 ��� _ <br /> ❑ Casing Protection___ _ t7 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? � Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout nnateria� ❑ Neat cement ❑ Bentonite ❑ Concrete '� High Solids Bernonite <br /> MATERIAL <br /> from__�to�ft. � ❑ yds. �bags - <br /> clay �ii Sc7Atl brOi�lA 80ft. Q 3'� trom____to ft. ❑ yds. ❑ bags <br /> from to_ ft. ❑ yds. ❑ bags <br /> Cla ra $Oft, 37 (�2 NEARE�Tj(NOWNSOURCEOFCONTAMINATION <br /> Y 3 Y � feet W�st directia�e�t�C lype <br /> Well disinfected upon completion? Q,Yes ❑ No tank <br /> sand S clay braxn saft 92 109 pUMP <br /> sand brown gOft, 1�9 128 � Notinstalled oateinstaued <br /> Manutacturer's name �e=�OtflL' <br /> Model number HP_1 1 T� Volts "O <br /> 1 L <br /> Length of drop pipe_ ft. Capacity g.p.m. <br /> Type: �]'Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �No <br /> VARIANCE <br /> Was a variance granted trom the MDH for this well? ❑ Yes C�No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. <br /> Leuthner Weli Inc. 10125 <br /> Licensee Business Name •� 'i' Lic or Reg.No <br /> �EF /y.;9 f `��-1. � .ri4`��,r.,� ' . ���1� <br /> ' Authorized Representative Signature Date <br /> Maurice L. Leuthner 12/15/Ol <br /> Name ol Driller Date <br /> LOCAL COPY 6 5 719 0 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />