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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �o���Y Name WELL AND BORING RECORD 5 7 0 2 8 5 <br /> Hennepin Minnesota Statutes Chapter 103! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 118 23 27 151 " 7/[5/95 <br /> �. ��, �, <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 1$7 6th Ave N ❑ CableTool ❑ �r��e� ❑ Dug <br /> ❑ Auger �-Rotary ❑ Jetted <br /> Show exact location of well in section grid wj�"X". Sketch map of well location. ❑ <br /> /I� Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N <br /> Bel�t� <br /> _� i i �_ � <br /> - ___ _-_ '� <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i � Domestic ❑ Communi PWS <br /> -�- -�- -�- -�- ❑ Irrigation ry ❑ Industry/Commercial <br /> i i i i i-�_ "'`� �-t;.`� � ❑ Noncommuniry PWS ❑ Remedial <br /> w E � ❑ Test Well <br /> � � i i T : i� a .l?{�n ❑ Dewatering ❑ <br /> .t�,�—_ �7',-:7 <br /> � � _r r +/2IMae . . ; �,,.� CASING Drive Shoe? ❑ Yes J�No HOLE DIAM. <br /> i _i_ _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> _� � � � l , �3 plastic �7 �lued <br /> S <br /> �-1 Mila-� <br /> CASING DIAMETEF WEIGHT j <br /> PROPERTY OWNER'S NAME ���Gy � in.to 1�6 ft. Ibs./ft. s i�.t15�' n. <br /> Phillip & Mar,� Hernande �, $ `� <br /> in.to ft. Ibs./ft. in.to tt. <br /> Prope wner's mailing address if different than well location address indic�e��Qqe. ____ in.to ft. __ Ibs./ft. in.to ft. <br /> IB�� ounty Koad 6 - - � SCRE OPEN HOLE <br /> Lang Lake, �t+i 55356 Make�$yC� from tt.to tt. <br /> Type tQ1�gC0 in Diam. <br /> SbVGauze Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC�(Vl�T�Fi LEVEL <br /> WELL OWNER'S NAME ��� ft.�I below ❑ above land surface Date measured �/'15/95 <br /> - Same <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping 75 g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑ Pitless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Emironmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ��[ Yes ❑ No <br /> HARDNESS OF Grout Material I[►Neat ceryept ❑ Ber�pite ❑ Concrete ❑,kiigh Solids eenronite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO lL � <br /> from 11 to �'f ft. ZS ❑ yds. 6l bags j <br /> - from to ft. ❑ yds. ❑ bags <br /> Tap Soil BTack 0 2 f�om to n. ❑ Yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION '� <br /> Cilc1� Y�IZ.OW .Z 1� feet direction __ type <br /> Well disinfected upon completion? ❑ Yes ❑ No � <br /> Clay Gr�y� 19 69 PUMP g/11/95 � <br /> ❑ Not installed Date installed <br /> Clay/Gravel Gray 69 93 Manufacturer'sname �Yers <br /> Model number HP 1V�ts <br /> Sxnd BZ'OWIl 93 11/� Length of drop pipe a� Capacity g.p.m. I <br /> Pressure Tank Capacity <br /> Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> Clay Grsy 114 117 <br /> ABANDONED WELLS �L, <br /> Does property have any not in use and not sealed well(s)? ❑ Yes !u No <br /> Sand/Gravel Mixed 117 151 <br /> VARIANCE <br /> � Was a variance granted from the MDH for this well? ❑ Yes �No <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,S4UflCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> �'' Stevens llrilling & Env. Serv. 86654 <br /> , , Licensee Business Name Lic.or Reg.No. <br /> �, _ . . . . . ,_ � _.. ..._._.",._ <br /> Authonzed Representative Signature Date <br /> Puu1 Swearing�r; <br /> Name ol Driller HE 01205-05(Rev.1/95) <br /> LOCALCOPY 570285 <br />