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WFL�"�!OCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD 6 4 9 2 2 2 Hennepin Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono 117 23 03 , ,. ,. 165 ry 7-7-d0 House Number,SVeet Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD 2150 Shevlin Dr, �roao 553 1 ❑ AugeeTool �otary ❑ JDett d Show exact location o(well in section grid with"X". Sketch map of well Iocation. Cl Showing property lines, roads and buildings. DRIILING FLUID WELL HYDROFRACTURED? ❑VES ❑NO N _, , , ,_ � bentonite FROM � to _ h. ; -,- -;- -, USE ❑ Monitoring ❑ Heating/Cooling i i � i �Domestic _i_ _a_ _i_ _i_ ❑ Irrigation ❑ Communiry PWS ❑ Indusiry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w e � � , !�C(,,� ❑ Environ.Bore Hole ❑ Dewatering ❑ i i i i -r -�- -r- -r T `V W i i i i +/2M e � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. , � L i � ❑ Steel ❑ Threaded ❑ Welded i- l i i 1 � �Plastic ❑ _ _ _ _ S �,M��e—� � CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME ! in.to�ft. _ �dl'�� Ibs./ft. � �i�$ �. Je t se Po t t in a ______ in.to ft Ibs/ft �in.to��. Property owner's mailing address i(different than well location address indicated above. __— __in.to ft. __ ____ Ibs./fl. in.to__ft. SS�A'e aS above SCRE�ETN OPEN HOLE Make"0$n from tt.to ft. " -�--�j—._ --. �?. Type��$,�(�le.�a $tt Diam. � SIoVGauze_._y_�_��_.__..__ ,.,___.Length_��i.�� ;. Setbetween _ 1 G�J�ft.and !LG ft. FITTINGS:�M��.,_)� iVJ �7� ST TI WATER LEVEL y� WELL OWNER'S NAME �� ___ h..�below ❑ above land suAace Date measured 7�'7"VD PU PING LEVEL(below land surface) +� Well owner's mailing address if different than property owner's address indicated above. 1��_ ft. after_._____ 4�5_.. hrs.pumping 30 g.p.m. WELLHEADCOMPLETION �hi.tewater " �Pitless adapter manutacturer_ _____ Model . ❑ Casing Protection _ Rr12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? J�Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material f 7 Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite _ , MATERIAL from�to��ft. � rl yds. ❑ bags from to ft. � ,�y�ls�❑ bags � to soil llow aoft 0 f�om��o�37-n natuta�- y�� bags ' NEAR T KNOWN SOURCE OF CONTAMINATIO� „� . �J��(�/ � C 7 S r� 90f t 1 w� O _ feet �/�C''��S� __ direction�� f type 1 1 f ��.[��`� Well disinfected upon completion? �YYes ❑ No C18 sand nr$ $Q,f PUMP ❑ Not installed Date installed �_10�0 ravel �� Y8 SOft 8 Manutacturersname ____�uj,$g___ _ Model number_._____ _____ _ __.__ HP_j�____ Volts �� C18 rave 1 brov �edium � Length of drop pipe_. __ =�________ tt. Capacity __ __ _ g.p.m. Type: �ubmersible �*LS.Turbine ❑ Reciprocating ❑ Jet Cl SBnd b d�n �I�d IS� 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 I�No TN# WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed 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. ; REMARKS,ELEVATION,SOURCE OF DATA,etc. on Stodola Well D�lling Cos,__I�c ��_ZZ 72 ; Licensee Business Name ,- Lic.or Reg.No. �/�� -- " 1-2 7-t30 -- - . � - � G�' '� Authorized RepreseM tive Signature Date �I18IlE__MBL�le�i8- 7"?��n '; 6 4 9 2 2 2 Name of Driller Date LOCAL COPY HE-01205-07(Rev.2/99)