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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> I.LOCATION OF WELL 1 MINNESOTA UNIQUE WELL NO. ^45 . <br /> •County Name WATER WELL RECORD iV+� <br /> 495 <br /> Hennepin <br /> Minnesota Statutes 156.4.01,08 /or Water Sample <br /> Township Name Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> N E <br /> Orono 1 1 8N s ?'1W w ,1? _ /-"L+7 t ' 160 ii. 4/7/92 <br /> Numerical Street Address and City of Well Location or Distance frond lntersecti.^ .. 6 .DRILLING METHOD <br /> i o— rr "': ❑Cable"tool 0 Reverse 0 Driven 0 Dug <br /> 480 Orchard Park Rd Long\ Laker Mn' 5.5 ' <br /> Show exact location of well in section grid with"X." •`' Sketch map of well location. 0 Hollow Rod 0 Air 0 Bored 0 <br /> N <br /> I <br /> t i Addition Name 30Rotary ❑Jetted 0 Power Auger <br /> __r__y_ _1__1_ <br /> t I � 6.DRILLING FLUID <br /> I <br /> .� �_ Block Number Flarniei Ci)11k gP1 <br /> wLXtl E 7.USE <br /> 3- __1I_._.t_ -:- __ 1 domestic 0 Monitoring 0 Heat Pump <br /> • i _ Lot Number 8 1 ❑Irrigation 0 Public 0 Industry <br /> f•m. ^/ <br /> -_�_ ;- 1 ,oc-c `' 0 Test Well ❑Municipal 0 Commercial . <br /> -i- - -r <br /> 0 Air Conditioning ❑ <br /> I mile---i 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address 0 Black 0 Threaded HEIGH 41=ftelow <br /> X��ffi indicated above. Surface 1 ft. <br /> ❑Galy. ❑Welded <br /> Drive Shoe? Yes_No_.X <br /> Albert Esco O 'tastic 0 <br /> 4 in.to 153 ft. Weight 1 _ 9 lbs./ft. min. t __It. <br /> 3. FORMATION LOG COLOR (HARDNESS OF ••. ., TO l in.to f:. !Ce e-!:: Ibs.'f: i •� •�6 n.:: <br /> FORMATION �-"' <br /> in.to ft. Weight lbs./ft. Win. tort. <br /> yellow clay brown soft 0 31 9.SCREEN Or'open hole <br /> Make Johnson from ft.to. ft. <br /> clay & sand gray soft 31 96 Type stainless steel m.. 2" <br /> Slot/Gauze 15 slot 4enh* FITTINGS: <br /> sand & clay gray soft 96 142 Setbetween 'ft.and ft. 5 ft . extension <br /> 10. TIC WATER LEVEL <br /> sand brown soft 142 160 f obelow ❑above Date Measured 4/7 <br /> land surface <br /> II. PUMPIN EVEL(below land surfA1ce) <br /> 30 <br /> ft.after hrs.pumping g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12. HEAD WELL COMPLETION <br /> ZiPitless adapter manufacturer whtietwater Model511 451 <br /> :❑Basement,offset 0 At least 12"above ground <br /> 0 Plastic casing protection <br /> 13.WELL GROUTED? cit Yes 0 No <br /> xO Neat Cement 0 Bentonite 0 <br /> IA. <br /> Grout material cement from 30 to 0 ft.cu.yds. <br /> mud & bentonite 160 _30 <br /> • _ <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> 50 feet NL___dirediani Sl C3P plumbing type <br /> Well disinfected upon completion?XO Yes 0 No <br /> 15. PUMP <br /> Date installed 4/9/92 0 Not installed <br /> Aermotor <br /> Manufacturer's name <br /> Model number n HP 3/4 Volts 2 2 0 <br /> • Length of drop pipe 0015[ ft. Capacity 1 0 g.p.m. • <br /> Material x of drosteel <br /> Pepe <br /> Type: d-Submersible 0 L.S.Turbine ❑Reciprocating <br /> ❑let ❑Centrifugal ❑ <br /> 16.ABANDONED WELLS <br /> Unused well on property? X7 Yes 0 No <br /> Use a second sheet,i/needed - Sealed O Permanent 0 Temporary EX Not sealed • <br /> 17.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATION <br /> • This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> Leuthner Well Inc. 10125 <br /> Licensee Business Name License No. <br /> Address Box 159, • Victor ' - , Mn 55386 <br /> Signed L/-''�f,i h <br /> ._ _ ,�_. /L _.. Date _ <br /> i� em4` E�zed --presentative S-5 <br /> Date <br /> Name of Driller ` <br /> 30M <br /> /74 <br /> MINN. DEPT. OF HEALTH COPY I 495545 5 5/7430M <br /> -------- _.__. /7830M <br />