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� <br /> � ��WELL�L�CATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> yName WELL AND BORING RECORD <br /> .�.. <br /> H@j1j1@p�A Minnesota Statutes Chapter 1031 6 2 4 9 Q 9 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 08 ,. ,,. ,, 272' n 4-29-� <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 3285 Northshore Drive Orono, Mn. 553g n CableTool ❑ Driven ❑ Dug <br /> ❑ Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> i � N i , Bentonf te FROM ft.to tt. <br /> _i_ _i_ _i_ _i_ <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i � Domestic ❑ Communit PWS <br /> _i_ _a_ _�_ _i_ ❑ Irrigation Y ❑ Industry/Commercial <br /> i i i i L�,E+ ❑ Noncommunity PWS ❑ Remedial <br /> w E {� ❑ Environ.Bore Hole <br /> i i i i � ❑ Dewatering ❑ <br /> i i r r ��ZM_1e x CASIN� Drive Shoe? Yes ❑ No HOLE DIAM. <br /> _i i _i_ _i_ I Steel �Threaded ❑ Welded <br /> r -�- � � 1 <br /> ❑ Plastic ❑ <br /> s <br /> �1 M'ile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 24T n I i Ibs./ft. 8 in.ro30 ft. <br /> Robert i�Taade � Associat s ;�.,o n. ,bs.,n �l��.�0�5�. <br /> Property owneYs mailing address if different than well location address indicated above. in.to n. ms.in. 3 �,�08 Z 2 <br /> SCREEN OPEN HOhE�' 2,9 <br /> 6't L. <br /> Make N� from ft.to ft. <br /> �► va�:. <br /> Type Diam. <br /> 5240 Nolan Drive SIoVGauze Length <br /> Minnetonka, �. 55343����3 Setbetween ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME _.__ 45 ft.�below ❑ above land surface Date measured '��29�9 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 1 ZO ft. after � hrs.pumping 60a i r g.p.m. <br /> WELLHEADCOMPLETION y,mite�rater <br /> �] Pitless adapter manufacturer YModel <br /> ❑ Casing Protection TJ 12 in.above grade <br /> ❑ At-grade(Ernironmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? C�Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat c ment ❑ Bentonite ❑ Concrete �High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from � to 30 ft. ���ds.�7 bags <br /> C1ay Br01ib S 0' 1 ' from to n. ❑ Yds. o bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAR/5�g.�7 N SOURCE OF CONT�pMjINATION1� Y�t� <br /> Sdnl� BrOi�n �J' 18� 5 � ��� feet !�/�'d� � f' direction°��type <br /> �.�.$Y Grey S 63� C�g,t Well disinfected upan completion? � Yes ❑ No <br /> PUMP �_�w hA . <br /> Se!!d Grey S 95' 10 �� Not installed ����ne " <br /> Manufacturer's name <br /> Cl�y 8oeks Grey H 100' 23 �Model number Ol fi12�8 HP Y� vons 230 <br /> � <br /> Length of drop pipe $� ft. Capacity �8 g.p.m. <br /> .S�1a2@ Sand�ta @ ��t ►r1 b�5� �4 �Type:�0 Submersible ❑ L.S.Turbine ❑ Feciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Sand�tone Grey 1i'h te M ��� ti�� Does property have any not in use and not sealed well(s)? ❑ Yes � No , <br /> _ <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes � No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> DO�i 3T4DOLA XELL D�ILLING C4. , iNC. <br /> Licensee Business Name �c,o�Reg.No. <br /> � � ' 2-29-00 <br /> Authorized RepreseMahve Signature Date <br /> Chnek Moore 4-29-99 <br /> , <br /> Name of Dri/ler HE 01205-06(Rev.7/98) ;a <br /> LOCALCOPY 6�L�909 <br />