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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 668027 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. I Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 4 196 tt 8-24-41 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑priven 4 ❑ Dug <br /> 2995 Wktertowa Rd Orono 5 356 ❑Auger Rotary LI Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well local n. ❑ <br /> y �SJ�yygqwi property Iiis, --- ---- _-- <br /> N i`�� + (iFos and buildi s. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> ! ti` Tv J.+�t r�11 prat er <br /> FROM ft.to ft. <br /> tt <br /> USEomesticO Monitoring ❑ Heating/Cooling <br /> ❑ Community PWS <br /> ❑ Irrigation ty ❑ Industry/Commercial <br /> i i , i .• ❑ Noncommunity PWS ❑ Remedial <br /> w i E T ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes o HOLE DIAM. <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> F116c- <br /> lastic ❑ <br /> s <br /> f- i Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME _ 4 in.to 11 all ft. 201-5 lbs./ft. in.to—30. <br /> Tony Eiden Company in.to ft. lbs./ft. l Lin.togt. <br /> Property owner's mailing address if different than well location address indicated above, in.to ft. lbs./ft. �i in.to_ft. <br /> 4140 Berkshire Lane M SCREEN* 1. OPEN HOLE <br /> Plyeau t h� 1'!11 55446 Make Johnson from ft.to ft. <br /> 1 TypeAtAk I st�.i Dam. <br /> Slot/Gauze .01 o Length _ 4* + 4" <br /> Set between ft.and rqir�ft. FITTINGS <br /> STATIC WATER LEVEL J <br /> WELL OWNER'S NAME 100 ft. elow ❑ above land surface Date measured A-26— 1 <br /> PUMPING LEVEL(( 2 <br /> below land surface) q- <br /> Well owner's mailing address it different than property owner's address indicated above. 18S ft. after hrs.pumping 30 g.p.m. <br /> ARL HEAD COMPLETION whi t ewa t e r <br /> /JP�{Pitless adapter manufacturer Mo el <br /> ❑ Casing Protection 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? Yes [_J No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement El Bentonite ❑ Concrete igh Solids Bentonite <br /> MATERIAL from 0 to_34ft. 1' 9-!=] yds.Xags <br /> from 30 to j a ft. nail Cf IVIL I bags <br /> clay yellow soft 0 20 from ft. ❑ yds. ❑ bags <br /> NEAR WN SOURCE OF CON MINATION � t1_ <br /> clay brown soft 20 84 feet FSS/ direction type <br /> Well disinfected upon completion? Yes ❑ No <br /> sand/gravel brown soft 80 140 PUMP <br /> �� <br /> ! <br /> 11 Not installed Date installed 1.004 0411001Clay 8"y soft 100 1 54 Manufacturer's name Aenwter <br /> Model number HP 1_ 5 Volts 230 <br /> sand tall soft 1 50 19� Length of drop pipe 147 ft. Capacity g.p.m. <br /> Type: I'Yubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes o 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 /> DonStodola Well Drilling Co., Inc. 27172 <br /> ce Fee Business Name �ic.or Reg.No. <br /> 12s14-01 <br /> Authorized Represen&7ve Signature Date <br /> Chuck Moore 8-24-01 <br /> Name of Driller Date <br /> LOCAL COPY � 668027 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />