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N'jLL L ' TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name — WELL AND BORING RECORD - 696480 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name --jTownship No. I Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ocom 118 23 26 y. 'h 246 10-7-03 DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool rrr❑r,-00000�����Dotar ❑Dug <br /> ❑Auger otary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number El1085 Tse arack Dr, Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes <br /> o <br /> Shop exact location of well in section grid with"X". Sketch map of well location. bmtodte FROM ft.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE ❑Monitoring ❑Heating/Cooling <br /> omestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> --- - - <br /> u Noncommunity PWS E]irrigation Remedial <br /> ❑Community PWS ❑Dewatering ❑ <br /> """""`------ <br /> i ` CASING OLE DIAM. <br /> w � � � � E� ` �� Shoe? ,�/ ❑No <br /> - C Dnve fires H <br /> feel hreaded 1 El Welded <br /> 'h Mile O J� Plastic <br /> "" ----------...... I ASI DIAMETER WEIGHT <br /> ' 111 CASING D g� <br /> S <br /> ^'" �. . . 4 in.to 219 ft. 11 lbs./ft. _�in.to— <br /> J in.to ft. lbs./ft. in.to�'1.a' <br /> PROPERTY OWNER'S NAME/COMPANY NAME - in.to ft. lbs./ft. to <br /> JIM FAXWS SCREEN OPEN HOLE <br /> Property owner's <br /> mailing address if different than well location address indicated above. Make FROM 219 ft. TO 245 ft. <br /> CriterW 78th alt Type Diam. <br /> Chanhassen, M 55317 Slot/Gauze Length _ <br /> Set between ft.and ft. FITTINGS <br /> STATITER LEVEL � <br /> ft. elow ❑above land surface Date measured 10-7-03 <br /> PUMPING LEVEL(belA land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> 210 ft.after 4 hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION y <br /> Well owner's mailing address if different than property owners address indicated above. ❑Pitless adapter manufacturer Mteater Model_ <br /> s ❑Casing Protection ❑12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> I <br /> Well grouted L es ❑No <br /> Grout material /'r]Neat cement ❑Bentonite ❑Concrete ;Xigh Solids Bentonite <br /> from__to 0 ft. ' _ ❑yds. [Kags <br /> from 0 to2112 ft. A ❑yds. >'lags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds.. ❑bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay ` ltlCliJ. 0 ZZ J --� feet - ' direction type <br /> D meii J. Well disinfected upon completion X Yes ❑No <br /> 11 <br /> clay gray soft 33 103 PUMP y��� <br /> ❑Not installed Date installed 10-24-03 <br /> sand brawn soft 103 i30 Manufacturer's name Aecwtor <br /> it Model number �, HP I Volts 230 <br /> n <br /> clay brown soft 130 193 Length of drop pipe 126 ft. Capacity g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> sed (fins) brain soft 193 2M ABANDONED WELLS <br /> —j Does property have any not in use and not sealed well(s) Ll Yes- o <br /> Clay red .soft W5 219 VARIANCE <br /> J 7 Was a variance granted from the MDH for this well? ❑Yes c TNk <br /> lfmetone red bard 219 Z4 WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,it needed Don Sto&la Well Drilling Co., Inc. 27172 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Business Name Lic.or Reg.No. <br /> —1IwM <br /> 4�,.-entative Signeture1 Date <br /> Chuck PToore 10-7-03 <br /> LOCAL COPY � 696480 Name of Driller Date <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />