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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD � 6 6 8 O 3 7 <br /> Hennepin Minnesota Statutes Chapter�031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 317 23 d4 ,, ,. ,. 115 tt 9-20-41'� <br /> House Number,Sireet Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> Z 6�1 Rai nep Rd �r�Q� ❑ Cable Tool f] Driven CI Dug <br /> J ! ❑ Auger 6tl�otary �7 Jetted <br /> Show exact location of well in seclion pri wi ". Sketch map of well location. ❑ � � .. <br /> E Showing property lines, <br /> --------- --- �--- ----------_-- -------- <br /> S roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? (.]YES O <br /> N <br /> � i i i �a t e r FROM ft.to_______ ft. <br /> -i- -i- -�- -� <br /> USE �] Monitoring ❑ Heating/Cooling <br /> � � i i �Domestic ❑ Communit PWS <br /> \ ❑ Irrigation Y ❑ Industry/Commercial <br /> -�- � -� i e ❑ NoncommunityPWS ❑ Remedial <br /> yy E ❑ Environ.Bore Hole <br /> i � � � ❑ Dewatering ❑ <br /> i i �r �r i � � CASING Drive Shoe? ❑ Yes .No HOLE DIAM. <br /> '2 e � <br /> _i � i _i_ I r;.�, � ❑ Steel ;7 Threaded ❑ Welded <br /> . i_ _ _ _i _ i � � J�rp�astic ❑ � <br /> S f <br /> �-1Mile� � f ��� <br /> �V CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �in.to I48 ft. �.�1. Ibs./ft. in.to 30 n. <br /> Patrick/I�irsten burton ��.+o h. IbsJft. in.��h. <br /> Property owner's mailing address if different than well location address indicated above. ___—__--in.to__._____ft. __.__ _Ibs./ft. _in.to ft. <br /> Ib417 L1�aer3ck Lsne SCREE _ OPENHOLE <br /> Aii�netonka, P4� 55345 Make �o�ga/�n f�om h.�o h. <br /> TyPe— —Q�St_--- ---Diam. - --- <br /> SIoUGauze �1 n Length $� _ <br /> Set between ___trtA ft.and ft. FITTINGS:_ <br /> i�T� 1Ty p-- <br /> STATIC W TE LEVEL Jl <br /> WELL OWNER'S NAME _—__��'______n.�elow ❑ above land surface Date measured ��Z�' 1 <br /> ; • PUMPING LEVEL(below land surface) +�/� : <br /> <; Well owner's mailing address if different than property owner's address indicated above. �O3 . ____h. after_____ 1�S__ hrs.pumping�71�+ _g.p.m. <br /> `� �L HEAD COMPLETION yhi t eva t�s <br /> �Pitless adapter manufacturer ______ Mod ._____________ .. <br /> ❑ Casing Protection__._._..____ _.,.___ _ ___ � 12 in.above grade :�� <br /> ❑ At-grade(Environmen[al Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> HARDNESS OF Grout Material� ❑ Neat cement ❑ Bentonit ❑ Concrete High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from___ � to �Q R � ❑ yds. ags <br /> from�Q_to_��ft. �$ f!'A 1 C€��ags <br /> Topsoil black sof t 0 3 from to n. o yds. ❑ bags <br /> j +� 8 NEARE ��y'yj N�SOURCE OF CONT MINAT�IQ�" — ,�---�.. ).1 <br /> C+B� g�$p $��� • J 7� V feet G �5 f direction� � �type <br /> Well disinfected upon completion? - ves ❑ No <br /> SSL�d CSEZ SOL t 30 1 i� PUMP � - <br /> ❑ Not installed Date installed _. �5["�16"V� <br /> Manufacturer's name Aer�o t o r <br /> Model number ____ _ HP ����j�lts `�� <br /> Length of drop pipe � ft. Capacity _ _ __ g.p.m. <br /> Type: f�Submersible ❑ L.S.Turbine ❑ Reciprocating C] Jet ❑ __ <br /> ABANDONED WELLS � ` <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Lym�o <br /> r <br /> VARIANCE <br /> Was a variance granted from[he MDH for this well? i7 Yes 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 irue to the best of my knowledge. <br /> Dan Stod 1T2 <br /> Licensee Business Name �c.or Reg. o. <br /> _._..�w _ � ; �-'; I2-17-fl1 <br /> .� <br /> - Authorized Repres ` �ve Signature Date <br /> Chnck �Ioore 9-2€�-C}1 <br /> Name o/Driller Date <br /> LOCAL COPY 6 6 8 0 3 7 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />