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_ - -a <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD � 6 7 3 H S H <br /> Hennepin Minnesota Statutes Chapter�03! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �rono lI7 23 7 ,, ,, ,, 39b n I-9-02 <br /> House Number.Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> I170 Gacden C�� Orono 5535 �1 CableTool ❑ Driven ❑ Dug <br /> 1 I l Auger ,�Rotary ^ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. I l ___ � <br /> Showing property lines, <br /> --�-—- --- ------- <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ' NO <br /> i N i , supe r ge I"g FROM ft.to_ ft. <br /> __ ___ ___ _i_ <br /> USE L ❑ Monitoring ❑ Heating/Cooling <br /> I I I I - -3 (`.<�y f� �� Domestic <br /> _i_ _�_ _�_ _i_ - " � ❑ Irrigation � Community PWS �] Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w e T _ �� t ❑ Environ.Bore Hole — <br /> i i i � " ❑ Dewate�ing ❑ <br /> i � -r i '/zIM.1e x CASING/� Drive Shoe? Yes ❑ No HOLE DIAM. <br /> _, _i_ _i_ _i_ � w f�'"� ,�fl�Steel ,k:] Threaded ❑ Weided <br /> i i i i <br /> ❑ Plastic ❑ <br /> �1Mile� , <br /> CASING DIAMETER WEIGHT , <br /> PROPERTY OWNER'S NAME � in.to 38� I 1 Ibs./ft. ��n� Q <br /> Charles Cudd Co. _--.— <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. __ Ibs./ft. �.�__ 6 <br /> 275 Market S�� �7C4� 139 SCREEN OPEN��� 346 <br /> Minnespolis, MN 554�5 Make ��om h.�o n. <br /> Type Diam. <br /> SIoVGauze Length__ <br /> Set between ft.and ft. FfTTINGS: <br /> STATIC T R LEVEL t <br /> WELLOWNER'SNAME ___ n.�below ❑ abovelandsurface Datemeasured 1_�O� <br /> PUM�ry��VEI(below land surface) � C 0 <br /> Well owner's mailing address if different than property owner's address indicated above. l ft. aker__._, hrs.pumping � g.p.m. <br /> �LL HEAD COMPLETION �i�;��a��r <br /> Pitless adapter manufaciurer �� Model <br /> �❑ Casing Protection �12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �}Yes ❑ No <br /> HARDNESS OF Grout Material �❑ Neat cemQqt CI Bentp9itp ❑ Concrete .�J Fygh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � <br /> from_ « to '��� ft. f ❑ yds. ❑ ags <br /> clap brown aoft p ig f�om ���o-3$�n. nature-I �y���� s <br /> from to__._____ tt. ❑ yds. ❑ bags <br /> NEAR T NO�WN SOURCE OF CONTAMINATION � /T(� <br /> clsy/gravel gray soft I8 110 � feet �i'/__owz1� direction � ' r rype <br /> Well disinfected upon completion? ❑ Yes ❑ No ��J C-� <br /> gravel/clay gray soft 130 13T PUMP <br /> clay gray �ediva� 137 �32 � Notinstalled Dateinstalled 1-�2-02 <br /> Manufacturer's name ���mfl t�r <br /> Model number � HP __ ��� Volts �+3�1 <br /> clay/sand/gr vel grs soft 232 �77 —�� <br /> Lengih of drop pipe____ ft. Capaciry g.p.m. <br /> sanda t one/�h Ie ye l i W� Type Ch Submersible ❑ LS Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ��� ��lu� 37? 39b ABANDONED WELLS �/. <br /> Does property have any not in use and not sealed well(s)? ❑ Yes L�'No <br /> VARIANCE <br /> Was a variance gran[ed from the MDH for this well? ❑ Yes p No TN# <br /> f <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/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 ktell Drilling Co. inc 27 ?2 <br /> --- _ __ - --- <br /> 4N�- Lice e Busme Name or Reg.No. <br /> �'`�' ��� _.�=.' , -'� 1-Z7-02 <br /> Authonzed Represe tive Signature Date <br /> �,t,t�n� Math�ws ---- 1-9-02 <br /> Name ol Driller Date <br /> LOCAL COPY 6 7 3 8 5 8 HE-01205-07(Rev.?J99) <br /> IC#140-0020 <br />