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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE W LL NO. <br /> County Name .,,Hennepin WELL AND BORING RECORD Jc 9 6 7 0 0 <br /> J Minnesota Statutes Chapter 1031 <br /> Ttynns8nNa�me Towns Fyp plp J Range Go,Z Section o. Fraction WELL DEPTH(co, feted) Date Work Completed <br /> 1111 ((JJ 1 ! �'4 i� f'77" 12- 19-97 <br /> '/. <br /> Ho je plu bey,%el Name,Ci a(d Zi Cgde of Well Location or Fire Number ILLING METHOD <br /> L_LL1 11tC}rCi{1L 1�}Y'eCi Lc�Zle Orono MN. Cable Tool ❑ Driven ❑ Dug <br /> or <br /> ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. r <br /> Showing property lines, <br /> roads and buildings. I <br /> L 'IILUID WELL HYDROFRACTURED? ❑YES it NO <br /> N7. <br /> FROMft.to ft. <br /> gg�� ❑ Monitoring ❑ Heating/Cooling <br /> J-_>_- _i_ X �CSromeon ❑ Community PWS ❑ Industry/Commercial <br /> W E ❑ Test Well - <br /> D Irrigation ❑ Noncommunity PWS ❑ Remedial <br /> - <br /> T"' <br /> ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes ET No HOLE DIA . <br /> HJ_i i L I; Steel El Threaded ❑ Welded <br /> - i- _ Plastic.. [}, <br /> 3 f <br /> GASI DIAMETER- WEIGHT <br /> PROPERTY OWNER'S NAME in to_,___ft _ �.: � __Ibs.fft. tn.to _ ft. <br /> �'rart�. E'�der�«'�Corrtpany <br /> - in-to— _ft. �- lbs/ft, inl td._—_ I <br /> Property owner's mailing address if different than well location address indicated above, in.to— __ ft_ _._._ _ lbs/ft, _ _in.to _ ft. <br /> 4 's UO BvekshiSe !.sane SCREEN OPEN HOLE <br /> ��yrnata th; <br /> MN. 55446` ohns°n <br /> Make from - ft.to ii ft. <br /> Type Stainless Steel ' Diam. <br /> Slot/Gauze Length g7 L <br /> Set between ft.and � ft!FITTINGS: / P <br /> STATIC�1'Fl�l� A <br /> LEVEL Y <br /> WELL OWNER'S NAME' ft. elow ❑ above land surface Date measured 12-19-97 <br /> PUMP�Ic) <br /> L)VSEL(below land surface) <br /> Well owner's mailing address If different than property owner's address indicated above. ft. after -S hrs.pumping 60 a Y- .p.m. <br /> �LLHEAD COMPLETION WhitewaterPitless adapter manufacturer Model <br /> ❑ Casing Protection 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑Yes ETNo }� <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement F Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from •fo ft. -3 ❑ yds. A6 bags <br /> from to _ft. ❑ yds. ❑ bags <br /> from to ft ❑ yds. [ bags <br /> _ NEARE RCE OF <br /> ( `� CON NATION <br /> ",l �. t' r <br /> -Y Grey � 1 feet r! direction' r/� type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> Sana '' :ne <br /> Grey c} 7 e3 <br /> PUMP <br /> v r - ❑ Not installed Da a Insta�lets <br /> C_l 6* 'kti c't_4 i7 <br /> Brown <br /> -1 160 It 2151 a d <br /> Manufacturer's name Y fi <br /> * <br /> Gravel <br /> , Ccry G7 ev H 215= 2 3 C, t Model number HP fes1135s <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Clay, Gravel. , BoUldera 60 Type: 1�6ubmersible ElL.S.Turbine ❑ Reciprocating ❑Jet ❑ <br /> t`� ABANDONED WELLS Xy <br /> tt Does property have any not in use and not sealed well(s)? ❑ Yes 4 No <br /> Sand Brown 5 280 7 VARIANCE yy <br /> Was a variance granted from the MDH for this well? 11 Yes [3CNo <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. , INC. ;717Z <br /> Licensee Business NaL' Reg.No. <br /> _ ,._ f <br /> `. 12-19- 7 <br /> ,0. <br /> Authorized RepresentatiVe Signature Date <br /> CHuck Moore 12-19-97 <br /> 1596700 , Name of Driller DateLOCAL COPYHE-01205.06(Rev. ) <br />