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WELL If <br /> MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Herne vi 655066 <br /> Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt. <br /> Orono 117 22-23-01 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> L 17 <br /> El Cable Tool F1 Driven E, Dug <br /> 64 To k R ❑ Auger 1-4 Rotary C 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? El YES I*NO <br /> " super gel-s <br /> FROM _-ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i Q Domestic ❑ CommunityPWS <br /> ❑ Industry/Commercial <br /> t7 Irrigation <br /> i ❑ Noncommunity PWS ❑ Remedial <br /> w eT El Environ.Bore Hole ❑ Dewatering ❑ <br /> � i i r ? , �� CASING Drive Shoe? ❑ Yes >il'No HOLE DIAM. <br /> -i i i i_ ,ti•�. ❑ Steel ❑ Threaded ❑ Welded <br /> - - - - -� I/Plastic 11g 1 <br /> E1 Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 138 ft _2dr 21 lbs./ft. 7 7/8 } <br /> Diversified Cons t rpet inn in.to ft. — _—----.__- lbs./ft. V '�.to 5 <br /> Property owner's mailing address if different than well location address indicated above. -. ...- __ in.to ft. lbs./ft. in.to ft. <br /> 7010 fiwy 7 SCREEN OPEN HOLE <br /> St Louis Park, TIN 55426 Make Johnson from _ ft.to ft. <br /> YPest.,�r.ainless st! Diam. - 311 <br /> Slot/Gauze fil n Length <br /> Set between* tj ft.and ff. FITTIN S' <br /> STATIC WATER LEVEL I V1w/f <br /> WELL OWNER'S NAME ft. 1(below ❑ above land surface Date measured kp 8 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. _ ft. after—_--__- hrs.pumping---4-5-g p.m <br /> WELL HEAD COMPLETION <br /> Di Pitless adapter manufactureryh Vodel <br /> '❑ Casing Protection k 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? Q Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material /❑ Neat cement ❑ Bentonite ❑ Concrete V High Solids Bentonite <br /> MATERIAL from_()_to a. 3 ❑ yds. 1�,bags <br /> from to �8�Jt atura ❑� bags <br /> clay yellow soft 0 22 from—to__ h n 11yds.Pbags <br /> 1 �f NEA.jEJT KNOWN SOURCE OF CONTAMINATION <br /> Cloy gray soft 22 55 -.(K) feet � 1-�4 direction / _type <br /> Well disinfected upon completion? y Yes ❑ No <br /> sand/clay gray soft 55 110 PUMP ! <br /> ❑ Not installed Date installed 6-26-01 <br /> sand brown soft 110 150 Manufacturer's name Ae rmo A P <br /> Model number HP 5 volts <br /> Length of drop pipe Itos ft. Capacity g.p.in <br /> Type: Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes lyNo <br /> VARIANCE 7 <br /> Was a variance granted from the MDH for this well? ❑ Yes No TN# <br /> WELL CONTRACTOR CERTIFICATION / <br /> Use a second sheet,if 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 /> Don Stodola Well Drilling Co., Inc. 27172 <br /> Licensee Business N e Lc.or Reg.No. <br /> ,►v <br /> s <br /> uthonzed Representative Signature ate <br /> Duane Mathews 2-23-01 <br /> 6 5 5 0 6 6 Name of Driller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />