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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 4 315 7 <br /> Henne�in Minnesota Statutes Chapter f03/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � Date Work Completed <br /> Orono I17 23 09 ,,, ,, ,. 110' tt 2-25-00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DPILLING METHOD <br /> 2865 L�Ltle OtChsrd �iap Ozo1� , Mn 553 6 ❑ AugerTool ❑ Driven ❑ Dug <br /> �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property li s, <br /> �lopd�and buildia�s. DRILLING FLUID WELL HYDROFRACTURED? p YES ❑NO <br /> - N - L Lt..- ,� BeaLonite <br /> i � i i X FROM fl.to ft. <br /> _ _i_ _i_ _i <br /> USE ❑ Monitoring ❑ HeatingiCooling <br /> i � � i �Domestic ❑ Communi PWS <br /> -�- -a- -�'- -�- <br /> ❑ Irrigation ty ❑ Industry/Commercial <br /> i � � i ❑ Noncommunity PWS ❑ Remedial <br /> yy E T ❑ Environ.Bore Hole <br /> � i i i �� ❑ Dewatering ❑ <br /> i i i -r '2IMia �'�"^� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _, , _, _ _,_ I I '•-- �� ❑ Steel ❑ Threaded ❑ Welded <br /> i - i- i i � <br /> /� �i Plastic ❑ <br /> �-1 M�ile-� �.✓ <br /> CASING D�METER �O� WEIGHT <br /> PROPERTY OWNER'S NAME �} ;,,.to K. SD$Z 1 ,bs.,n. 7 ;�,�8 � <br /> PARAGE31►I DBS I GNERS b BLD $���.�o h. ibs.in. ���.�011 t1�. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> 3550 Fainra? I.ane SCREEN __ _ OPENHOLE <br /> Miaaetoaka, I�. 55305 Mak�ohnaaon 1 from f�.�o n. <br /> Type ta A eQa Steei Diam. <br /> SIoUGauz� Length <br /> � <br /> Set between � � ft.and � ft. FITTINGS � <br /> - STATIC WATER LEVEL <br /> WELL OWNER'S NAME �5� ft. C+�below ❑ above land surface Date measured ��1 S�0 <br /> PUMPING LE1VEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ��1 ft. after � hrs.pumping 30 g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑ Pitless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATyION <br /> Well grouted? QRes G No <br /> HARDNESS OF Grout Material ❑ Neat c ent ❑ Bent ❑ Concrete igh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �' °�'b ][ <br /> from to ft. ❑ yds.a bags <br /> Lakef i 11 ----- S 0' 1� from co n. ❑ Yas. ❑ bags <br /> from to tt. ❑ yds. ❑ bags <br /> 1 .y NEARF��y p+�y�/MSOURCE OF CONT�/�v�J/Nyf N .r �J ?"(C,// <br /> Ciay ge110 3 10 y� ✓ !J feet Yf/`��s/ direction ��type <br /> Well disinfected upon completion? LTYes ❑ No�/� �Sr� �.7 <br /> Clay Grep S 22 102 PUMP �G � <br /> Sa�� T8n S 102 1 1� ❑ Not installed Date installed �_�O_O4 <br /> Manufacturer's name �VA P'Q <br /> --�-T�-=-� <br /> Modelnumber J�QSQ� _ HP�_ Volts 7�n <br /> Length of drop pipe 04 ft. Capacity g.p.m. <br /> Type: ❑ Submersible 17 LS.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 �Tlo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet il 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 reporl is true to the best of my knowledge. <br /> DON STODOLai ie1ELL DRILLING G0. • INC. <br /> � Licensee Bu �ess Nam � d�ia.or�eg.No.'1�'1 j 7 2 <br /> � ._�r...._ �_ - <br /> Authorized Representative Signature Date <br /> g-r...�t.pt;b� 2_z s_nn <br /> Name o/ �il/e� a e <br /> LOCAL COPY 6 4 315 7 HE-01205-07(Rev.2/99) <br />