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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Hennepinnnepin Minnesota Statutes Chapter 1031 <br /> 8 0 5 9 4 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> Oronc 1 1 3 2..3 -4,-, 18() ' 4-4-97 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 20 Orono Orchard Rd. N. Oronc, MN. ❑ Auger (:}';Rotary ❑ Jetted <br /> Show exact location of well in section grid with X. j 53 9 1 Sketch map of well location. 0 <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N q water <br /> USE ❑ Monitoring 9 ❑ Heating/Cooling <br /> i t%Domestic ❑ CommunityPWS <br /> ❑ Irrigation ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> w E <br /> C� 0 Test Well <br /> 1 1' Q ❑ Dewatering ❑ <br /> r- <br /> Y2,'", z x t(/4 L. (` CASING Drive Shoe? 7 Yes ❑ No HOLE DIAM. <br /> L I ..---� *Steel *Threaded ❑ Welded <br /> 1 " <br /> ❑ Plastic 0 <br /> s <br /> I1MIle--I c) <br /> CASING DIAMETER 1 6 9 WEIG1T1 f <br /> Ji.• <br /> PROPERTY OWNER'S NAME in.to ft. lbs./ft. in.to ft. <br /> Jim Murphy <br /> __in.to ft. lbs./ft. in.to ft. <br /> Property owners mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> 3U Orono Orchard Rd. SCREEN OPEN HOL <br /> Orono, Mn. 55391 Make N/AA from I6`J ft.to I8t ft. <br /> Type _Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS: <br /> ___ _ STATIC W TER LEVEL <br /> x 4-4-9; <br /> WELL OWNER'S NAME ft. Q below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 165 ft. after 6 hrs.pumping "(• g.p.m. <br /> WELL HEAD COMPLETION Wtlltewater <br /> a Pitless adapter manufacturer Model <br /> ❑ Casing Protection Ek 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? p Yes 0 No <br /> HARDNESS OF Grout Material ❑ Neat cement 0 Bentonite 0 Concrete ❑ High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TOi <br /> from 6 to .`.l' 0 yds. ❑hags <br /> from to ft. 0 yds. 0 bags <br /> - B1ac(>' ,.. i ` �, r from to ft. ❑ yds. ❑ bags <br /> NEARS NOWN SOURCE OF CONT (NATION 410 <br /> r.• <br /> Clay Y e 1l O ' 'i,i.- 1 feet _. �S F" direction type <br /> Well disinfected upon completion? QLYes 0 No S"e 1 `r ie <br /> Clay Grey ,if: PUMP <br /> ❑ Not installed Date installed 4- 10-9—i <br /> Sand WHIt.e ' S Manufacturer's nam�9 r,bnr, ,0r 1� w5 <br /> n S `'t` l> Model number C"� V`� '�' " HP Volts <br /> Length of drop pipe 84 ' s:; g.p.m. <br /> Clay-Gravel Grey S ;.t .i,)% ` 1 ` Pressure TankCapaciry 1 —911 1 <br /> Type: C'Submersible D L.S.Turbine ❑ Reciprocating 0 Jet 0 <br /> Sand-Gravel Tan 1 ' 1 ''4'ABANDONEDWELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes LI 140 <br /> Sandstone-Shale White 14-11 1 .vi). ' 1f;.-VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes L'No <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 reportLis <br /> true to the best of my knowledge.f, Aq <br /> DON STODOLA WELL DRILLING CO. , INC. <br /> Licensee Bus ame -Lic.or Reg.No. 27 <br /> 1 7 <br /> -' ." .=f J u a f <br /> Authorized Representative Signature Date <br /> Fred Leiby 4-4-97 <br /> Name of Driller Date <br /> f,Or A.! COPY <br /> HE-01205-05(Rev.1/95) <br />