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WELL LOCATION MINNESOTA DEPARTMENT OF HEALT ` ! MINNESOTA UNIQUE WELL NO. <br /> ) ;�..% <br /> County Name WELL AND BORING RECORD''7IfF 6 7 7 8 5 5 <br /> Hennepin Minnesota Statutes Chapter 103lnp r <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) 3 ?7 , <br /> ���rte Work Completed <br /> Orono 117 23 5 144 `'I` r L,r. �f 5-29-02 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD i7(?N//'''1 <br /> 0 Cable Tool 0 Drivel?? ❑ Dug <br /> 372 Westlake St , Orono 55356 ❑ Auger ;rotary 0 Jetted <br /> Show exact location of well in section grid wilt . Sketch map of well location. 0 <br /> T�`w Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? El61 <br /> YES NO <br /> N `C <br /> __ i ---- J \\ super gel- FROM ft.to ft. <br /> 1 USE O Monitoring ❑ Heating/Cooling <br /> Fd'Domestic <br /> 0 Community PWS CI Industry/Commercial <br /> a o ❑ Irrigation <br /> ❑ Environ.Bore Hole ❑'Noncommunity PWS 0 Remedial <br /> w i E �` ff ❑ Dewatering 0 <br /> r r �� f' <br /> /ZM. I CASING Drive Shoe? 0 Yes C.No HOLE DIAM. <br /> ---- • <br /> � --- steel El Threaded ❑ Welded <br /> 1 ` \ JC lastic 0 <br /> S <br /> I ,oras I -_ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to tuft. sdr 21 lbs./ft. 77/@.to ft. <br /> Steiner & Koppelman in.to ft. lbs./ff.66 in.to."t'•ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft.© m.to fft. <br /> 18340 Minnetonka Blvd SCREEN OPEN HOLE <br /> Wayzata, MN 55391 Make Johnson from ft.to ft. <br /> J Type s t fen st ee 1 Diam. 2" <br /> Slot/Gauze .010 Length AS f 4 <br /> Set between 136 ft.and 144 ft. FITTIN S_2„a30" laader <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME --42 <br /> AME _ ft. below 0 above land surface Date measured w/kp ' <br /> - � 5-24-02 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 1 20 ft. atter 1 hrs.pumping 48 g.p.m. <br /> WELL HEAD COMPLETION trrhi t ewe t e <br /> ,'Pitless adapter manufacturerrode <br /> O Casing Protection [x/12 in.above grade <br /> O At-grade(Environmental Wells and Borings ONLY) / <br /> GROUTING INFORMATION <br /> Well grouted? Cp"Yes 0 No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material 0 Neat cement 0 Bentonite 0 Concrete 511-ligh Solids Bentonite <br /> MATERIAL from-_to____,30._ft. 3 0 yds. Ci#bags <br /> clayyellow soft 0 17 from 3p to 136 tt. natural- f ft. bags <br /> from to ft. G�iL�� y s bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION -j <br /> clay gray medium 17 43 70 1 feet SouTIE`� direction �pe <br /> Well disinfected upon completion? R'Yes 0 No <br /> coarse gravel white soft 43 47 PUMP f <br /> 0 Not installed Date installed 6-11-02 <br /> clay/gravel gray soft 47 63 Manufacturer's name <br /> Model number HP 1 . L <br /> 5 Volts 2 3J0 <br /> clay gray 63 94 <br /> Length of drop pipe 80 ft. Capacity g.p.m. <br /> 131 Type: ubmersible 0 L.S.Turbine 0 Reciprocating 0 Jet 0 <br /> gravel/clay gray soft <br /> 94 •7 ABANED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes 61No <br /> sand gray soft 131 144 <br /> VARIANCE �'C <br /> Was a variance granted from the MOH for this well? 0 Yes Qif 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 /> Don Stodola Well Drilling Co., Inc. 27172 <br /> Licensee Business Name Lic.or Reg.No. <br /> ./ !/ / ���� ' ' 7l . <br /> 4.71-.Se-..- -presentative.ig ire'- r- Date <br /> Nam o de/e Mathew 5 29-q .. - <br /> LOCAL COPY 6 7 7 6 5 5 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />