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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 615576 <br /> Hen Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Or on 164 n. 9-10-98 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> n <br /> El Cable Tool El Driven ❑ Dug <br /> 150 N Shor r We Orann ❑ Auger „14lotary ❑ Jetted <br /> Show exact location of well in sectio grid with" Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> N <br /> d natural FROM ft.to ft. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> ,,ffomestic ❑ CommunityPWS <br /> ❑ Irrigation ❑ Industry/Commercial <br /> ((('''''''''l <br /> ❑ Noncommunity PWS ❑ Remedial <br /> W E :: <br /> �L� ❑ Test Well <br /> ❑ Dewatering ❑ <br /> / e n CASING Drive Shoe? ❑ Yes o HOLE DIAM. <br /> ae <br /> _..J! � ❑ Steel ❑Threaded 11 Welded <br /> �Flastic ❑ <br /> s -- <br /> 1 Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 n.to 156 ft. 1 9 lbs./ft. 8in.to 3 <br /> Robert Mattson Cont '`y <br /> 4 <br /> in.to ft. lbs./ft. fl-k-in.to ■ <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to _ft. <br /> 10420 0 f.9 t h Ave „y SCRFW)"nson OPEN HOLE <br /> 1�f L 'i iY Mak from 1 from. ft.to fl. <br /> Plymouth, MN 55442 Type st8 n ess Steel Diam. Z __ <br /> Slot/Gauze -010 Length 41 i 4 <br /> Set between 15&-ft.and--1-6,4--tt. FITTINGS: Y <br /> STATIC WATER LEVEL f <br /> WELL OWNER'S NAME 90 ft./below ❑ above land surface Date measured 10 9— —9 <br /> PUMPING LEVEL(below land surface) L7” <br /> Well owner's mailing address if different than property owner's address indicated above. Iri O -ft. after 2 hrs.pumping�_g.p.m. <br /> 7PiL HEAD COMPLETION <br /> tless adapter manufacturer wh f t esa t e r Model <br /> ❑ Casing Protection f 2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? !/Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete C�ligh Solids Bentonite x <br /> GEOLOGICAL MATERIALS COLOR MATEfiIAL FROM TO <br /> from to 30 ft. 3 ❑ yds. lXbags <br /> from_to 156 ft. n ❑ yds. Elbags <br /> Top soil black soft C from to ft. ❑ yds. ❑ bags <br /> NEAREST NOWN SOURCE OF CONTAMINATION <br /> Clay yellow Soft 5 25 feetdirection �t�HQ�/j'bPe <br /> Well disinfected upon completion? Yes ❑ No <br /> Clay gray soft 25 90 PUMP <br /> ❑ Not installed Date installed 11-24-98 <br /> Sand, fine gray Sort 9C 14q Manufacturer's name Red .racket <br /> Model number 1 5t1CNSt_Gh7C1 7 CC 5 volts <br /> Sand/Gravel brown hard 161�•T <br /> Length of drop pipe 126 ft. Capacity 18 g.p.m. <br /> Type: Xsubmersible ❑ L.S.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 XNo <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 <br /> .� Licensee us/ness m tf.*. • 172 <br /> 12-21-98 Represaawfive Signature Date <br /> Chuck Moore <br /> Name of Driller Date <br /> LOCAL COPY 15 5 7 6 HE-01205-06(Rev.9/97) <br />