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, �.. WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD 6 6 0 5 51 xenne in Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed OCono 117 23 10 �� 181 n 11-29-01 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug 2155 Cacria e Lane � ❑ Auger �{Rotary ❑ Jetted Show exact location of well in section grid wi�h�'X". Sketch map of well location. ❑ _ _____ � Showing property lines, e ..i',.? .�oads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES � O + " j� ,�� water i i � i � FROM r ft.to R. -i -i- -�- -i- p � USE .1 ❑ Monitoring ❑ Heating/Cooling i i i i A�Domestic _i_ _�_ _i_ _i_ ❑ Irrigation ❑ Community PWS ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w i ' I e T _ ❑ Environ.Bore Hole ❑ Dewatering n . i i i r +2IM.1e � � �� CASING Drive Shoe7 ❑ Yes No HOLE DIAM. � i i i i . ❑ Steel ❑ Threaded ❑ Welded _i_ _ i_ _i _ _i . l�... � � �Plastic ❑ S ,, �1Mile-� .... ' CASING DIAMETER WEIGHT r PROPERTY OWNER'S NAME k in.to1 73 ft. �O1 Ibs./ft. in.to 3�. JOn ��h3 C�n$t ruC in.to ft. Ibs1ft �in.to�,_$_�,ft. Property owner's mailing address if different than well loca�ion address indicated above. _ _in.to ft. ,_.._ Ibs./fl. in.to R. SCREE OPEN HOLE 600 HWy 269 S, Ste 155 ,��ga� Make from ft.to ft. St Louis Park, Mri 5542b TYPe s sin ss steei Diam. SIoUGauze •OZ o Length�� }�� Setbetween �7'� fLand__�a�_R. FITTINGS: 9M�4A« �Il_ STAp�LVATER LEVEL 1 7 WELL OWNER'S NAME �� ft.�,below ❑ above land suAace Date measured 1 Z�29 i PUAAPIIyCa{EVEL(below land surtace) - Q Well owner's mailin address if different than ro ert owner's address indicated above. 1��j ft. after � hrs. um in +O m. 9 P P Y — _ P P 9 9P VyELL HEAD COMPLETION �6 Pitless adapter manufacturer whi t ewa�� Mo el ❑ Casing Pro[ection_ �2 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION r Well grouted? �Yes ❑ No HARDNESS OF Grout Material ❑ Neat ce�'�j nt ❑ Benton ❑ Concrete� igh Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO trom " to �� ft. F-`..•,w�' ❑ yds.�bags from 3� to i 73 tt. n$�si� ��c�.�] bags topsoil black oft 0 3 from to h. o yds. ❑ bags � sand/gravel broWn pf't 3 �$ "EA'K�WaSOURCEOFCor sw rS f S-�-. J j'4 G-� feet � direction ype Well disinfected upon completion? Yes ❑ No clay bco�n oft 1$ 40 PUMP ❑ Notinstalled Dateinstalled Z2�12�� cla OraV oft 40 165 Aermotor � O ! Manufacturer's name e s Model number HP �� Volts �3� .. ssnd/grsvei bro�n oft 165 i81 Lengthofdroppipe I05 ft. Capacity g.pm. Type��Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �I No VARIANCE Was a variance granted from the MDH for ihis well? ❑ Yes �No TNM WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minneso[a Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. on Stodola �eII Drilling Co.� INc. 27 72 Licensee Business aaae • �� 'l� Lic.or Reg.No. . r� ,;�. s f� ��__ � ZZ�Z1�'�� Authorized Representative Signature Date C / - - �<=T-��1 1-� n Name ol Driller ate�� �oc�,�.coP,r 6 6 0 5 51 HE-0120507(Rev.2/99) ��#,40-0020