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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 3 <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> 578 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) ft. Date Work Completed <br /> Orono 117 221 04 A h V, 271 ' 2- 13-9fi <br /> House Number,Street Name.City,and Zip Cc Qe of Well Location or Fire Number DRILLING METHOD <br /> l„ line orono, _N' ❑ Cable Tool 11 Driven ❑ Dug <br /> is a. 'I: >llc+ 1' C;: . ❑ Auger EARotary ❑ Jetted <br /> Show exact location of well in section grid with"X'. S IS:1,6 Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID Bentonite <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> J.Domestic ❑ Community PWS <br /> Y O�.r t /Commercial <br /> EI Irrigation ❑ N 1r ity � I <br /> w e ❑ Test Well <br /> I _, -r -r CASING Drive Shoe? ❑ Ygs•,C,] No,, r -- -HOLE DIAM. <br /> _i_ 41 Steel F] Threaded — El Welded <br /> El Plastic ❑ <br /> ��Mi1e� / [.�+✓<`/.✓ SING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME r• in.to 2-5 8 ft. Ibs./ft. 7 i7 8 <br /> moony Eiden Company <br /> in.to ft. Ibs./ft. "itg �. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make Johnsen from ft.to ft. <br /> Type 5tai nIt-5--, C;�'f-4PI Diam. 2 <br /> Slot/Gauze 1�) 10 1,1 0 _ Length i. 1+4 '+Z ' <br /> Set between 2 5'8 ft.and 27 1 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 1 ft 7 below ❑ above land surface Date measured —1 i-9 <br /> PUMPING LEVEL(below land surface) <br /> Well.owner's mailing address if different than property owner's address indicated above. ft. after 115 hrs.pumping 35 g.p.m. <br /> WELL HEAD COMPLETION �11i eSdi{ 1:k r <br /> 3t Pitless adapter manufacturer Model <br /> ❑ Casing Protection Ix 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? XI Yes q No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat c ent I4 Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL from (I to �_ _ft. i'is ❑ yds.R bags <br /> Zi <br /> Clay Black .5 <br /> from to ft. C1 yds. ❑ bags <br /> � t � <br /> 7 from to ft. ❑ yds. L1 bags <br /> Cloy Yellow �j J t NEA •KDIOt�NSOURee OFCON /{RAIR f T�N7 direction <br /> Clay <br /> disinfected upon completion? K Yes S/❑ No <br /> Clay Grey S10 PUMP �� �y <br /> El Not installed Date installed 2-23—% <br /> Cloy, Grovel Grey L` j(: r Manufacturer's name QXII.dgg _ _ ? 7r� <br /> Model number / HP • �'VoltQlts 430 <br /> Length of drop pipe 147 ft. Capacity� g.p.m. <br /> Clay, Sand, ravel Brown S 16 i5 75t <br /> Pressure Tank Capacity S� 01 <br /> Type: 0 Submersible C3L.S.Turbine El Reciprocating E1 Jet 1:1Gravel, Sant' a'ello�� �7 _i8 27i <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes -� No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes X 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 report is true to the best of my knowledge. <br /> DON S` UDOLA WELL DRILLING CO. , <br /> LicenseeBusines Name � _ Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Fred Leiby 2-13--96 <br /> Name of Driller Date <br /> LOCAL COPY 573578 HE-01205-05(Rev.1/95) <br />