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� � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 2 3 5 � 9 <br /> Henne i n Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Orono 1 Z 7 23 03 ��. �. ��. 100' 2-1�-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 217Q Sh�V21A Driwe Or0�3O I�1N' S5391 ❑ Auger .�7 Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". � Sketch map of well location. ❑ A � <br /> - ! � wing property lines, � <br /> J�,W roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES NO <br /> N � Bentonite <br /> _, , , ,_ �N FROM h.ro n. <br /> � -�- -�- -, <br /> .i� ..� USE ❑ Monitorin <br /> i � i i [�Domestic 9 ❑ Heating/Cooling <br /> ❑ Community PWS ❑ Indust /Commercial <br /> - i a i i C Irrigation ❑ Noncommuniry PWS ❑ Remed al <br /> w E ❑ Environ.Bore Hole <br /> � i i i ❑ Dewatering ❑ <br /> , I r r '/ZMi1e � CASING Drive Shoe? ❑ Yes �l No HOLE DIAM. <br /> j _i_ _ i_ _i _ _i_ ❑ Steel ❑ Threaded ❑ Welded <br /> � , � � g <br /> 1 �Plastic ❑ Ij2e <br /> s <br /> �—,M��e� �,y�t L <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � �Z h. 1.� ibs.in. $ �� <br /> ��� Wi ens in.to in.t ft. <br /> in.to ft. Ibs./ft. _1���_Q� <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 /> x Make_ from ft.to ft. <br /> TYPe— ..—t—+ � <br /> Sti a i rrs�g��-��' <br /> SIoUGauze Length � �._ <br /> Setbetween '�2 ft.and ],�� ft. FITTINGS: Z n X 3O" �(� � �� <br /> � STATIC WATER LEVEL <br /> WELL OWNER'S NAME � ft.�9,f below ❑ above land surface Date measured 7—1 n--g <br /> PUMPING LEVEL(below land surface) <br /> Well owners mailing address if different than property owner's address indicated above. _�_ ft. after 2 hrs.pumping �n a 1.r g.p.m. <br /> WELL HEAD COMPLETION <br /> Q�Pitless adapter manufacturer Li}.� i-ef.r�}a r Model <br /> ❑ Casing Proteclion �1 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �LYes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite <br /> MATERIAL from�to��ft. 2• <br /> �_ ❑ yds.�l bags <br /> from to ft. ❑ yds. ❑ bags <br /> TOp 503.1 Hla�k S 0' 2 � from co n. ❑ Yas. ❑ bags <br /> NEAREST N� yWNfSOUFCEOFCONTAMINA�ICON (r� t� <br /> Clay �r�:y � �f �4/ _ � feet G.S� direction��i ! type <br /> Well disinfected upon completion? �I Yes ❑ No <br /> C�..,� FSrfJWT� S `xV t PV� PUMP <br /> ❑ Notinstalled Dateinstalled G"a2�79 <br /> Water �dAta f'sL'@ � $�� �.fl�� n�anufacturer'sname R�C� Jacket <br /> Model number HP 1 voic5 Z 3 Q <br /> Length of drop pipe V J� ft. Capacity 1� g.p.m. <br /> Type:�1 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �I No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes 4 No TN# ��� <br /> WELL CONTRACTOR CERTIFICATION <br /> _ Use a second sheet,il 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 me best of my knowledge. <br /> DON STODOLA I�E:.L DRILLING CO. , IA7C. <br /> ice e Busines �rne Lic.or Reryg.No. <br /> f 2 /172 <br /> :!-r <br /> Authorized Rep sentative Signature Date <br /> Chuck :��ore 2-IO-99 <br /> Name ol Driller Date <br /> LOCAL COPY 6�3 5 8 9 HE-01205-06(Rev.7/98) <br />