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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 572707 <br /> Hennepin Minnesota Statutes Chapter 103/ <br /> T 3pohip�Naame To�wrlsf�No. R�j No. Section No. ctioNW NE WELL DEPTH(completed) Date Work Completed <br /> 11 4 91 tt 8/6/96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 2600 Thoroughbred Lane ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger Rotary ❑ Jell <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ <br /> Showing property lines, polo <br /> roads and buildings. DRILLING FLUID <br /> N Bentonite <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> 1K Domestic ❑ Communit PWS <br /> El Irrigation y ❑ Industry/Commercial <br /> �- ❑ Noncommunity PWS El Remedial <br /> w E T r„__,,,,-_,/ ❑ Test Well ❑ Dewatering ❑ <br /> /ZM1e /'E CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> ❑ Steel ❑ Threaded L-1 Welded <br /> pQ Plastic ❑ <br /> Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 86 ft. 200 lbs./ft. 81 in.to 60 ft. <br /> Lecy Construction in.to ft. lbs./ft. in.to�ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to _ ft. <br /> 10340 Viking Drive SCREEN OPEN HOLE <br /> Make Ja eofrom ft.to_____...__ft. <br /> Eden Prairie, Mn 55344 Type rYl. Diam. <br /> Slot/Gauze Length - Y— <br /> Set between ft.and 91 ft. FITTINGS: K ae er <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 42 ft. rsroelow ❑ above land surface Date measured <br /> PUMPIN4YVEL(below land surface) 3 50 <br /> Well owner's mailing address if different than property owner's address indicated above. L ft. after hrs.pumping C g.p.m. <br /> AWELL HEAD COMPLETION Whitewater S-S-4 <br /> Pitless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 1� Yes [I No <br /> HARDNESS OF Grout Material ❑ Neat ce t *13ento to ❑ Concrete ElHigh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO `�° <br /> from to ft. 71yds. 11bags <br /> t med. 0 5 from to ft. ❑ yds. E] bags <br /> Tod; soil black <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNO OURCE OF CONTAMINATI <br /> clay brown med. 5 I9 floor drain <br /> y feet direction type <br /> clay blue med. 19 48 Well disinfected upon completion? AYes ❑ No air t e s a d <br /> PUMP 8/8/96 <br /> ❑ Not installedDate t II d <br /> sand & gravel mix mod. 48 91 Manufacturer's nar� Stal"YIt <br /> Model number S' /5M HP 3/4 Volts <br /> Length of drop pipe 85 ft. Capacity 1 <br /> Pressure Tank Capacity <br /> Type: f�rSubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS 5� <br /> Does property have any not in use and not sealed well(s)? ❑ Yes `r 1 No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ]EI 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 /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> R.E.S. Well Drilling 27276 <br /> Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Dag <br /> Robert E. Stodola, Jr. 8/7/96 <br /> Name of Driller HE-01 205-05(Rev.1/95) <br /> LOCAL COPY 1572707 � <br />