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WELL'OCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name <br /> WELL AND BORING RECORD Hennepin i Minnesota Statutes Chapter 1031 �[- 8 0 5 5 5 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orc>n0 l 1 b _ 1 1. 1 1-5-96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> / t: 6'?r�tt33 t t_;k;11 C?ctCl �,� ?ll(3 I1. �`5 3-�t5 El Cable Tool El Driven ❑ Dug <br /> ❑ Auger 19 Rotary ❑ 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 BentoniteN <br /> I 1 I I <br /> USE El Monitoring ❑ Heating/Cooling <br /> I Domestic ❑ Community PWS <br /> EI Irrigation ty ❑ Industry/Commercial <br /> I ❑ Noncommunity PWS ❑ Remedial <br /> W, E El Test Well ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes ❑'No HOLE DIAM. <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> 1 ❑'Plastic ❑ <br /> S <br /> —1 Mile _ <br /> JQ 7,5— f i tJ+�..� ,ice rCASING DIAMETER WEIGHT <br /> / <br /> PROPERTY OWNER'S NAME ) <br /> in.to ft. lbs./ft.1 . 9 7n.to- ; <br /> h. <br /> F,to ew'and Develt^oment in.to ft. tbs./ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. - _ lbs./ft. _in.to ft. <br /> t� <br /> Corporation SCREEN OPEN HOLE <br /> 106?9 Brunswick Circle Make JGtiiiscin from ft.to ft. <br /> BioC)Ti i IQ_ t:on, Mn.-55438 Type c .. 3 Aq Diam. <br /> SIoUGauze T t 1 t f Length K. <br /> P.Set between t ft.and (�ft. FITTINGS: X r �` <br /> STATI WATER LEVEL _ <br /> WELL OWNER'S NAME wi 0 ft. E3''below El above land surface Date measured 1 G- 0- 6 <br /> PUMPING LEVEL(below land surface) <br /> [- <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping 3 u a i g.p.m. <br /> WELL HEAD COMPLETION <br /> EXPitless adapter manufacturer Whi to w>I4. .IF%b lel <br /> ❑ Casing Protection 112 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 01 Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ❑ H' h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO f. _, <br /> from to ft. ❑ yds. 1!' bags <br /> Clz--i J Brown � t � 1 L, , from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST WQW .SOURCE OF CONTAMINATION _ c F` <br /> Sand Tan S 1 1 ` 1`_?u t rte', feet 4. .�Z - % direction -.-G-f type <br /> Well disinfected upon completion? Wes ❑ No <br /> Clay/Gravel Reddish Brown 15C ' 1 f o PUMP <br /> ❑ Not installed Date installed 3- 1-97 <br /> Water :7:.nO 1 ",1` 1 7L 1 19 1 'Manufacturers name to J aCkQ-t <br /> C Model number 1-d l+ ='!--CN L'1 C_1;1 Volts <br /> Length of drop pipeff. Capacity 22 g.p.m. <br /> Pressure Tank Cap aci ' '1 - rialupi on <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 E u No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes Ei'qo <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 Eiii0l)OLA WELL DRILIJING CO. , iNC 27 1' <br /> Licensee Business Narne ,.,. Lic.or.Reg.No. <br /> Authorized Representative Signature Date <br /> (Aluck Moore 12-- -9t' <br /> /� <br /> i Name of Driller Date <br /> I.-OCAL COPY <br /> 58 05 5 AJ HE-01 205-05(Rev.1/95) <br />