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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> - County Name WELL AND BORING RECORD 5 7 2 7�. 7 <br /> j-j��yl�a�j,� Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WE�L DEPTH(completed) Date Work Completed <br /> Orono 327 23 4 NW .SW SI� 1.51 n l�/�Y/9b <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHUD <br /> °�7� S�11:3 c..�LX (�'"1 r�1@ ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger C�}.Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ <br /> Showing property lines, T <br /> '`�� roads and buildings. DRILLING FLUID <br /> " � �Cj w�d t::T' <br /> _� � � �_ � <br /> ,- -;- -,-- -, r <br /> I I I `; USE ❑ Monitoring ❑ Heating/Cooling <br /> �Domestic ❑ Communi PWS <br /> -�- -a- -�- -�- ❑ Irrigation �' O Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> �,..._ <br /> w e� i ❑ Test Well <br /> i � i i ❑ Dewatering ❑ <br /> i , i -r ,/2M.�a � CASING Drive Shoe? ❑ Yes C�No HOLE DIAM. <br /> _i i _L_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i -i- i i <br /> E�Plastic ❑ <br /> s <br /> F---1 Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.ro 1'�7 R. Ibs./ft. � in.to "i�n. <br /> A & 'i` DeV�1Cl�lIl�Zlt In.to__n. �bs.m. �in.td`iLn. <br /> Property owner's mailing address if different than well location address indicated above. in.to_ ft. IbsJft. in.to ft. <br /> SCREE OPEN HOLE <br /> Make aY�� from ft.to ft. <br /> Type �V� Diam. <br /> SbUGauze � Length 7� <br /> set between i 47 ft.and 1�J Z ft. FITTINGS: � �dCk+�1" <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME a 1 fl.�] below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. �� ft. after � hrs.pumping 5� g.p.m. <br /> WELL HEAD COMPLETION <br /> L�Pitless adapter manufacturer w h i t e��a te r Model .��r'3�t3 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONIY) <br /> GROUTING INFORMATION <br /> _ Well grouted? �l Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement C�Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL from �5 to � ft. ❑ yds. ❑ bags <br /> clay p,rQ�jpl ��(;(� � c�jj from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> IQ�CI• NEAREST KNOWN SOUFiCE OF CONTAMINATION <br /> �:iay j31Ut: ��z.d �� ,�� =7� feet . ���+�r� direction `���t''r type <br /> Well disinfected upon completion? �1 Yes ❑ No r <br /> �and � yravel �ix m�ct. 49 bl PUMP 12/"l/96 <br /> c 1 a y �71 UL ��q� �1 b� � Not installed Date instal�ed <br /> Manufacturer's name � — <br /> ModelnumberlUP�F02JJ— HP 1 vonsr��� <br /> �t�11C� �c `.�rdV-t��'Z TR1X SU��i �rJ' 1�� Lengthofdroppipe r �� i��ap�city_ 2►� g.p.m. <br /> Pressure Tank Capacity �r <br /> s a nd y i:.1 3 Y �.}�.I3 e'�' S O f� L I�J 1 2 7 Type:�] Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> 5 d��� .fJ�GT(f1 C�ii�:.,�• 1�� 1 rJ� Does property have any not in use and not sealed well(s)? ❑ Yes {9 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,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 the best of my knowledge. <br /> H.E.S. 4��11 Brilli�i; i7i7� <br /> Licensee Business Name Lic.or Reg.No. <br /> � �_ , �-�..�"'r`-.�:a� ,: �� ,l �G� <br /> Authorized Representative Signature Date <br /> Kot��rt E. Stodc�la, �r. llj3l�� <br /> Name o/Driller HE 01205-OS(Rev.1/95) <br /> LOCALCOPY j ?�7 �� <br />