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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Nare - • WELL AND BORING RECORD <br /> Hennepin5 8 8 9 3 2 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed C+ <br /> "0.40c t 10-9-% <br /> C.r£cax; 117 2w !>9 v. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> e t. . �)- i, ❑ Cable Tool ❑ Driven El Dug <br /> 850 Old Crystal Bay Road Orono, 1.55tt ❑ Auger a Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> -, roads and buildings. DRILLING FLUID �.,./..,, <br /> N <br /> i H i�t� L. <br /> ,1 r USE ❑ Monitoring ❑ Heating/Cooling <br /> I <br /> Domestic ❑ CommunityPWS <br /> _ ❑ Industry/Commercial <br /> I-, CI Irrigation <br /> 0 NoncommunityPWS <br /> i ❑ Remedial <br /> yy i E T ❑ Test Well 0 Dewatering ❑ <br /> -r---r- I <br /> f - V,M��./ CASING Drive Shoe? ❑ Yes ❑ o HOLE DIAM. <br /> L ❑ Steel <br /> CIThreaded 0 Welded <br /> lastic ❑ <br /> S <br /> Mile <br /> CASING DIAMETER WEIGHT <br /> �r <br /> PROPERTY OWNER'S NAME in.to 100 <br /> n. 1.9 lbs./ft. r <br /> . V§ 31i <br /> Lake Associates in.to ft. lbs./ft. b 1,'„�Ae 1:On. <br /> - <br /> Property owner's mailing address if different than well location address indicated above.c� in.to ft. lbs./n. in.to ft. <br /> 1212East Wayz to Blvd. SCREEN HOLE <br /> C?�dsCI3 <br /> Wayzata, Mn. 55391 Make , from ft.to ft. <br /> Type <br /> Stainless Steel , <br /> YP t <br /> Diam. . 8 t <br /> o <br /> Slot/Gauze 10/10 Length ° <br /> Set between 100() n.and 1 4.ft. FITTINGS: t 80~w/ '- ` <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME . _ft. X below 0 above land surface Date measured 1G-9-96 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. jl' ft. after hrs.pumping ? air g.p.m. <br /> WELL HEAD COMPLETION <br /> 1 Pitless adapter manufacturer ` "#'- `�` Model _.._ <br /> O Casing Protection all,12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 4 Yes 0 No <br /> HARDNESS OF Grout Material Neat cement ❑ Bentonite, Concrete y igh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ID <br /> from �) 's� f0 <br /> tft. E?a ❑ yds. O='bags <br /> from to ft. 0 yds. 0 bags <br /> Clay I3rcw l `' 0' 201 from to ft. ❑ yds. 0 bags <br /> NEAREST- / <br /> -y K,NO�WN>SOURCE OF CONTAMINATIOa„� + _ <br /> l- �' ( i l ty) Grey r,t.. t 90' ! 4/ feet ` C)r- 141 direction -..>CP! `C'type <br /> Well disinfected upon completion? l(Yea 0 No <br /> W6ter Sand Grey _ '.'r 108'PUMP <br /> 0 Not installed Date inst GouldsIled <br /> 1(:-14-ab <br /> Manufacturer's name Goulds <br /> Model number 188..1�i 4 7f'T. 13F cyolts 23C; <br /> f <br /> Length of drop pipe �''r ft. Capacity 1 g.p.m. <br /> Pressure Tank Capacity #26 X-Trcl <br /> Type: 3'Submersible ❑ L.S.Turbine 0 Reciprocating ❑ Jet 0 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes L No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑'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 /> WN STODOLA WELL DRILLT.JNa CO., INC. 27172 <br /> Licensee Business Name Lic.or Reg.No. <br /> 10-9-96 <br /> Authorized Representative Signature Date <br /> C:huclt Pcxx;i:e 1 -< -(it.. <br /> Q Name of Driller Date <br /> LOCAL COP'( 5 8 8 9 3 2 HE-01205-05(Rev.1/95) <br />