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s �e •_ <br /> ELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name Hennepin WELL AND BORING RECORD 596690 <br /> Minnesota Statutes Chapter 1031 <br /> Township Ime Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 04 248 <. 11-21--97 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> (f V U +�.�Itr4 (�hbj-ed Lane �}rUn®r1. 5 �j El Cable Tool riven El Dug <br /> ❑ Auger otary ❑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 /> N <br /> Water FROM ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> [Abomestic <br /> _i_ _ _ _ _ _i_ ❑ Community PWS ❑ Industry/Commercial <br /> ❑ Irrigation ❑ Noncommunity,PWS <br /> w El Test Well ❑ Remedial <br /> ❑ <br /> T Dewatering ❑ <br /> -r -�- -r- -r <br /> /zwe CASING Drive Shoe? ElYes 10440 HOLE DIAM. <br /> ❑XSteel ❑ Threaded ❑ Welded <br /> ❑ Plastic ❑ <br /> s <br /> 1 Mile <br /> CASINO DIAMETERA WEIGDR.4 1 •y 1/6 3 t <br /> PROPERTY OWNER'S NA in.to 7 ft. lbs./ft. �/ irr 3 � t <br /> n.to ft. lbs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> in.to ft. lbs./ft. in.to ft. <br /> SCREEN Yn OPEN HOLE <br /> Make Ga� SE�Il from ft.to ft. <br /> Type Stainless Steel Diam. <br /> Slot/Gauze ]1 1 0 Length <br /> Set between _ 2_39 1 ft.and----2_4_&1ft. FITTINGS: 34 <br /> STATIC�ty�4�R LEVEL <br /> WELL OWNER'S NAME Tony Eiden Company ))LL ft.* below ❑ above land surface Date measured 11-21-97 <br /> PUNJPIIP LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. L ' ft. after hrs.pumping 25 g.p.m. <br /> 41L/0 Berkshire Larne WELL HEAD COMPLETION <br /> Plymouth, Hn.554'46 EXPitless adapter manufacturer rWh t _W a 1' Model <br /> ❑ Casing Protection ❑ Xin.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑ Yes ❑ No yy <br /> HARDNESS OF Grout Material ❑ Neat cement� Bentonite ❑ Concrete ❑ h Solids Bentonite <br /> 'Ai <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 10 <br /> LL 9 <br /> from - to ft. 2 2 ❑ yds. EX bags <br /> { ' 3 + from to ft. Elyds. ❑ bags <br /> Clay Yellow S <br /> from to ft. ❑ yds. ❑ bags <br /> C1? `NEAREEV 90URCE OF CONT�AAIjJv y{,��} A <br /> Clay Grey S 3( 1 1 �+5 feet ` �Y direction �C�! TIC pe <br /> Well disinfected upon completion? ❑ Yes ❑ No • <br /> Sand-Gravel Tan S 118' 1351PUMP <br /> ❑ Not installed qgto 1n all 1-30-98 <br /> Clay Grey Si 135 ' 2G Red Jacket <br /> l Manufacturer's namq — <br /> UMSIM; 230 <br /> Clay-Gravel Brow b3 '2001 �✓�. :Modelnumber t16b* <br /> HP fe <br /> Length of drop pipe ft. Capacity 1 rr g.p.m. <br /> $Type: 9 Submersible ElL.S.Turbine EI EI ElSand Y l l •W 5 2301 G 11 - <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑ No <br /> VARIANCE XX <br /> Was a variance granted from the MDH for this well? El Yes E No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,it needed 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 knowled e. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. ��aa DON S`I'ODOLA WELL DRILLING Co. � INC. <br /> RECEIVF7 <br /> Licen Business Name Lic.or Reg.No. 27172 <br /> f 11-21-97 <br /> APR 13 1999/ <br /> Authorized RepreseridtiveySignature Date <br /> CITY O V _ iC Fred Leiby 11-421-97 <br /> 5 9 6 6 9 0 Name of Driller Date <br /> LOCAL COPY HE-01205-06(Rev.9/96) <br />