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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 7 7 8 6 8 <br /> Hennepin Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> fr. <br /> Orono 118 23 33 % 228 7-8-02 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> G 0 Cable Tool 0 Driven 0 Dug <br /> 170 Wear Lane N, Orono 56356 0 Auger Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well loca on.\I 0 <br /> Showing property li esy' <br /> roads and buildi psi DRILLING FLUID WELL HYDROFRACTURED? ❑YES ( QO <br /> N <br /> I , water FROM ft.to__ ft. <br /> — USE 0 Monitoring 0 Heating/Cooling <br /> IDomestic ❑ CommunityPWS <br /> ,y i 1 0 Industry/Commercial <br /> a Li <br /> ❑ Irrigation El Noncommunity PWS 0 Remedial <br /> �'� 0 Environ.Bore Hole CI Dewatering 0 <br /> w i E Tu _ <br /> r r <br /> L -__ S, <br /> � VZM�Ie ` CASING Drive Shoe? 0 Yes yr No HOLE DIAM. <br /> ---- <br /> ❑ Steel ❑ Threaded 0 Welded <br /> Ir ❑ <br /> S - <br /> 1 Mile-- <br /> i : ,j, , __ i:, ,: N CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'StNAME 4 in.to 215 ft. 2.01 lbs./ft. $_in.to_30 <br /> Scott Berkey in.to ft. lbs./ft. 61 in.to 'l�fL8 <br /> Property owners mailing address if different than well location address indicated above. in.to ft. lbs./ft. . in.to�' ft. <br /> same as above SCREEN OPEN HOLE <br /> Make Johnson from ft.to ft. <br /> Type stainless steael_Dian. 2 <br /> Slot/Gauze .010 Length R it ♦ 4 E + t 1 <br /> Set between 21` ft.and 228 ft. FITTINGS: a't' �9 <br /> 6 U : P <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 120 ft. C below 0 above land surface Date measured p2 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 210 ft. after 1 hrs.pumping 30 g.p.m. <br /> WELL HEAD COMPLETION <br /> ,Pitless adapter manufacturer wh i t eva t e yodel <br /> ❑ Casing Protection 1:3,�I2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) /` <br /> GROUTING INFORMATION <br /> Well grouted? tEYes 0 No <br /> HARDNESS OF n Grout Material res <br /> cement ❑ Bentonite 0 Concrete ,o.a,/High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from 0 to_ Q ft. 3 0 yds. f(bags <br /> from 30 to ft. nal❑f i:.l bags <br /> topsoil slack soft 0 1 from to ft. 0 yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay gray soft 5 80 --?1'-'1(-) feet �JL-�1 direction .�) t ..L type <br /> Well disinfected upon completion? 9 /es 0 No <br /> sand brown soft 80 120 PUMP r� <br /> 0 Not installed Date installed 7'-9-02 <br /> clay/sand gray soft 120 215 Manufacturers name Aermotor <br /> C .�+�� Model number HP 1.5 Volts 230 <br /> sand gray soft 215 _y� Length of drop pipe 147 ft. Capacity g.p.m. <br /> Type:Jy��/�ubmersible 0 L.S.Turbine 0 Reciprocating 0 Jet 0 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes ?No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes ,'No TN# <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 Stddola Well Drillin&o 1 g.4 Inc. 2717 <br /> Licen --Business Name <br /> --- Ate/- - <br /> ���hiSnze•Represent: 'Signature ate <br /> Chuck Moore 7-8-02 <br /> Name of Driller Date <br /> LOCAL COPY 6 7 7 8 6 8 HE-01205-07(Rev.2199) <br /> Ir`..1 An nn')n <br />