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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESqEelQUE WELL NO. <br /> County Name WELL AND BORING RECORDJ H Q.J 9 S <br /> Hennepin Minnesota Statutes Chapter 103/ C <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> l TL;II f; 1 17 L iii. 2-14 ' <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> '521- <br /> Thoroughbred Lane Orono ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ❑Aotary ❑ Jetted <br /> Show exact location of well in section grid with"X'. N• t3 rO' JSkV map of well location. 11/ �"SShowing property lines, <br /> roads a <br /> N _1 j"fG' G E1(,7 and buildings. DRILLING FLUID <br /> BeTltuTTltB <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> y,/ L X 1( Domestic ❑ Community PWS ❑ Indust /Commercial <br /> -� - - -i- -i- ❑ Irrigation <br /> [I Noncommunity PWS di <br /> w E T L] Test Well y ❑ Remedial <br /> I ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑h(es ❑ No HOLE DIAM. <br /> lct Steel IN Threaded <br /> Threaded ❑ Welded <br /> -� ❑ Plastic ❑ <br /> S <br /> 1 Mile-� <br /> CASING DIAMETER WEIG T / <br /> PROPERTY OWNER'S NAME n.to t 6�ft. _ bs.ttt. /? 8 3i, <br /> LeGran Hones in.to ft. _--_—_ Ibs./ft. � eft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. tbs./ft. <br /> i. SCREEN OPEN HOLE <br /> 115021 9"t h +ane N.Y;. Make Jc-tf T::cin from ft.to ft. <br /> Blaine, Mri. 5544 Type-- �''t az nlr! s Ste( t Diam. ^,tt <br /> Slot/Gauze Length <br /> Set between ft.and 2 f:4 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 12 S ft. EXbelow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ;.�9 ft. after r hrs.pumping !j g.p.m. <br /> WELL HEAD COMPLETION <br /> 5Pitless adapter manufacturer Sz3h i + i.: +-. n r-Model <br /> El Casing Protection 4 IX 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? [-];.Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL FROM TO <br /> GEOLOGICAL MATERIALS COLOR i <br /> from �� to .jL'r ft, L.�� ❑ yds. ❑}bags <br /> from to ft. ❑ yds. ❑ bags <br /> lay Bl41G .) ti from <br /> NEARES�T-1 NOWN SOURCE OF CONTAMINATION <br /> Clay Yell ,W S 3 feet direction � +~f c type <br /> Well disinfected upon completion? IX Yes ❑ No <br /> Clay Gree rJ it. 1 b ` PUMP 7---28-97❑ Not installed Date Zrlled <br /> cane r�`ctl2 f)j ` 91mot' Manufacturer's name � Qr <br /> Model number HIP 1 Volts _ <br /> 1 � 9 p pipe Capacity -g.p.m. <br /> l,l"ly Grev � nth of dro i e 1�=7 t ft. Ca aci i <br /> �t 14 1 <br /> Pressure Tank Capacity 1, (oc4 l <br /> 'L� 1 > t 1 : <br /> Type: 1.4 Submersible ❑ L.S.Turbine El Reciprocating El Jet ❑ <br /> Sand w/C:la\- b :cl. J Very SC)§ . <br /> ABANDONED WELLS <br /> '--i a.n Gravel Clay Br tJ n snit 2091 'does property have any not in use and not sealed well(s)? ❑ Yes LI jyo <br /> VARIANCE <br /> Clay Gre S [,i t� 121,10 Was a variance granted from the MDH for this well? ❑ Yes 4 No <br /> 1.`' WELL CONTRACTOR CERTIFICATION <br /> �� Tl d Use a second sheet,if ne�dbbl Cur J .i.(?k i ! / This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <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. <br /> Licensee BusineserName Lic.or Reg.No. <br /> _71 1... <br /> Authorized Representative Signature Date <br /> F, ec LeiiDy 4-2.8-97 <br /> Name of Driller Date <br /> !.00AL COPY1580598 HE-01205-05(Rev.1/95) <br />