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MINNESOTA DEPARTMENT OF HEALTH <br /> CountyName MINNESOTA UNIQUE WELL NO. <br /> WELLName LOCATION WELL AND BORING RECORD <br /> 6 4 9 2 3 5 <br /> tennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELLDEPTH(completed) Date Work Completed <br /> itOrono 117 23 07 , 51 ' 8-3-00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 1000 Wildhurst Trail Orono, Nn. 55364 0 Cable Auger 0 IRotary 0 Jetted <br /> Show exact location of well in section grid with°X".( A.. '`�4Ls1- Sketch map of well location. 0 <br /> 1.4)14r 1 Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? 0 YES f�MO <br /> I <br /> I <br /> N !` <br /> x t,/611.. Quick-gel <br /> FROM_ ft.to ft. <br /> USE 0 Monitoring 0 Heating/Cooling <br /> 1 i It Domestic <br /> ❑ Community PWS ❑ Indust /Commercial <br /> ❑ Irrigation <br /> 0 NoncommunityPWS Industry/Commercial <br /> I 1 E ❑ Environ.Bore Hole ❑ Remedial <br /> ❑ Dewatering 0 <br /> I r CASING Drive Shoe? 0 Yes FNo HOLE DIAM. <br /> 1 1 1/I2Ma, <br /> 1 L 0 ID ❑ Steel ❑Threaded 0 Welded <br /> S 1 <br /> 1 Plastic 0 glued. <br /> 1 Mil,- I <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 2443 ft. SDR21 lbs./ft. 7 7/8 39 <br /> ROBERT WAADE & ASSOC• __ in.to ft. lbs./ft. 6 in.i ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to _ft. • lbs./ft.- in.to ft. <br /> 3286 Northshore Drive SCREEN OPEN HOLE <br /> Orono, Mn. 55391 Make_Johnson_ from tt.to . ft. <br /> Type Stainless Diam. 2- <br /> Slot/Gauze 018 Length 8' <br /> Set between x,43 ft.and _ft. FITTINGS:_21_3[. ■3A kpac ker <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 65' till below 0 above land surface Date measured 8-3-00 <br /> PUMPING LEVEL(below land surface) ,. <br /> Well owner's mailing address if different than property owner's address indicated above. 240' ft. after 2 hrs.pumping 40 g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑7.Pitless adapter manufacturer wh i tF t e son r Model <br /> Casing Protection 9/12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) l <br /> GROUTING INFORMATION <br /> Well grouted?1❑ Yes 0 No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material 0 Neat cement 0 Bentonite 0 Concrete XHigh Solids Bentonite <br /> MATERIAL <br /> from-0 to 30 ft. 30_3_ <br /> 0 yds.j bags <br /> from__30_to 3 ft. p Atli rail, yds. 0 bags <br /> Top Soil black a 0' 2' from to ft. 0 yds. 0 bags <br /> �w <br /> S NEA T KNOWN SOURCE OF CONTAMINATION <br /> Clay yeleov S 2' 28' fO' feet ale' 7` direction 0 / type <br /> Well disinfected upon completion? I Yes 0 No S' (A,, 6 rt- <br /> Clay Gray $ 28' 104' PUMP <br /> ❑ Not installed Date installed 9-21-01 <br /> clay/gravel gray s 104' 120' Manufacturer's name Aermotor <br /> Model number HP 1.5 Volts 230 <br /> play gray 8 120' 1804 <br /> Length of drop pipe 105 ft. Capacity g.p.m. <br /> Type: I<Submersible 0 L.S.Turbine 0 Reciprocating 0 Jet 0 <br /> _clay/gravel gray a 180'236' ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes , No <br /> eared tan a 236 '251 ' VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes ]QJ 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. a� <br /> 1 s , s els_7.:'ine4 ' r - c...'algNo. • 172 <br /> -t � � f' _ 9-26-01 <br /> Authorized Represen ative Signature Date <br /> • <br /> DuuRne Mathew 8-3-00 <br /> 6 4 9 2 3 5 Name of Driller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />