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� <br /> F��:������ <br /> MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> oEntyNO eATION ` ;! f� � ?""�yELL AND BORING RECORD <br /> � � • Minnesota Statutes Chapter1031 5 9 1 5 4 5 <br /> 't'I..Slrif..}�11'1 �_ .�;_,,_,: <br /> Township Name Township No. Range . Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n <br /> ,, .i. �. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOO <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> f7 Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". - Sketch map of well location. i�J _ _______ <br /> Showing property 6nes, <br /> roads and buildings. DRILLING FLUID <br /> N ' <br /> i i i i_ � �� :�5 <br /> _1_ '-' _i_ _i �� �' . <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> � � i i Domestic <br /> _�_ _�_ _�_ _�_ � � � � ❑ Community PWS ❑ Industry/Commercial <br /> i , -..,���� �i� ,•� ❑ Irrigation ❑ Noncommunity PWS ❑ Remedial <br /> ; y,� ' I E .,..l,� ❑ Test Well ❑ Dewatering ❑ <br /> -r -�- -r- -r T <br /> i i i i ,�'M e � CASING Drive Shoe? X] Yes ❑ No HOLE DIAM. <br /> _i i L � I � Steel ❑ Threaded ❑ Welded <br /> i- - i- i i � <br /> - s �! � ' � i - { � r_ ;-.._-�-__� 1 ❑ Plastic ❑ — - <br /> ! <br /> �1 Mile-� -�.��...�� <br /> —"".'."""-. � � - �`" CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME <br /> 4 in.to 1 13_R _ _ IbsJft. t'i in.to�j�ft. <br /> in.to _ft. _ Ibs./fl. � in.toy__J,__j_ft. . <br /> Property owner's mailing address if diflerent than well locafion address indlcated above. in.to _tt. Ibslft. " __1_�� �i i ry� <br /> �23� .�!• plymouth �d SCFiEEN OPENHOLE <br /> Make trom ft.to ft. <br /> �iinnetonka, MN 55305 Type SL"a1�12a�,S Diam l <br /> SIoVGauze �� _ _Length � � <br />- � Set between 117 R.and 1 x tj ft. FITT�,r��' j���;� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME h��J tt�Q7 below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) � <br /> Well owner's mailing address if different ihan property owner's address indicated above. lj� ft. afler � hrs.pumping ,y�� g.p.m. <br /> WELL HEAD COMPLETION <br /> �7 Pitlessadaptermanutacturer W't]1teWr"]1:F±iL ModelS—��� <br /> C7 Casing Protection_ CJ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> 4 <br /> GROUTING INFORMATION I <br /> � Well groutetl? � Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout tv�ateria� C Neat cemern ❑ Bentonite ❑ Concrete ❑ High So�ids eentonite <br /> MATERIAL from�g_�o__�_tt. � ❑ yds.�] bags <br /> , from to ft. ❑ yds. ❑ bags <br /> Sand Clcl $Zoidll Med 0 21 from to n. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Cla � Gravel Blue Mi M�d 'll 3 ---�� feet �}ja�� _directiorLj��_j�t�pe <br /> � Well disinfected upon completion?h'CI Yes CJ No <br /> Cla Hlue Med 30 36 PUMP <br /> � ❑ Not installed Date mstalled ���7;�f� <br /> Manufacturer's name ��+.�;_��,-4i, � � -^ <br /> ' Sz1riL� � Gravel MfX SOft �6 lUS Modelnumber HP �. vous l:�U <br /> Length of drop pipe C��t ft. Capaciry l�it g.p.m. <br /> sr�ji�i �,'la� B,1(je SQgt ,��� 11� Pressyure� TankCapacity_ <br /> �A�tQ Type�L7 Submersible ❑ LS.Turbine ❑ Reciprocaling ❑ Jet � _ <br /> �} ���a ABANDONED WELLS �y <br /> f ' Does property have any not in use and not sealed well(s)? ❑ Yes •''C] No <br /> VARIANCE <br /> A <br /> Was a variance granted from the MDH for this well? � Yes Xp No -. <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,eta The information contained in this report is true to the best of my knowledge. <br /> 1�E5 Well Dxilling t7t" <br /> Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> r2onert E Stodo' <br /> Name ol Driller Date <br /> LOCAL COPY 5 915 4 5 HE-0,zo�,Re�.,,�5, <br />� <br />