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r' �_'�""---A NESOTA UNIQUE WELL NO. <br /> WELL LOCA ION MINNESOTA DEPARTMENT OF HEAL� C17Y r;F <br />� ,^• � '� : <br /> CounryName WELL AND BORING REC�FtD . �� <br /> H r • � Minnesota Statutes Chapter f03/ �� % ! 5 915 0 4 <br /> Township Na Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Com�leted <br /> arono 117 `l:, 4 'W riik S�i i 38 " :,/8/9 / <br /> �. ,. ,. <br /> House Ntu1mbe,Street Name,Ciry,and Zip Code ot Well Location or Fire Number DRILLING METHOD <br /> 319V jxSSeX �(��(j C7 CableTool Iy���� priv� ❑ Dug <br /> f7 Auger j{7 �pta 1��� ❑ Jetted <br /> Show exact lo tion of well in section grid with"X". � � Sketch map of well location. �1 ._ ��i�i _ _ <br /> �) Showing property lines, <br /> � roads and buildings. DfiILLING FLUID <br /> " water <br /> � � � � <br /> -� - �- '�' -�- �,,..._..---' USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i I }Q Domestic ❑ Communit PWS � <br /> 'I Y ❑ Indust /Commercial <br /> -'- - - -�- -'- �V ❑ Irrigation ry <br /> i i i i � ❑ Noncommuni�y PWS ❑ Remedial <br /> w e T � � ❑ Test Well <br /> i i i i - ❑ Dewatering n <br /> � i r ,�2IM�a CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ _L_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i - i i <br /> ZC] Plastic ❑ <br /> s <br /> i Miie-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY WNER'S NAME � in.to 131 tt. L0� �bs./ft. <br /> -3�n�o b b n. <br /> . A & �' Devr�lopment in.to ft. _ Ibs./ft. 4 in.t�4 ft. <br /> Property owner mailing address if diHerent ihan well Ixation address indicated above. in.to ft. __ Ibs./tt. in.to__ft. <br /> �J /S S fiS�C CZ.rCl� SCREEN OPENHOLE <br /> Orono, �N 55355 Make Jayco from ft.to ft. <br /> Type_ �V C. Diam. <br /> SIoUGauze 1 2 .Length � � <br /> Set between ],_,�_.1_fl.and�ft. FITTtNGS: - <br /> STATIC WATER LEVEL <br /> WELL OWN 'S NAME �C] ft.�below ❑ above land surtace Date measured <br /> PUMPING LEVEL(below land surface) � � <br /> Well owner's m iling address if diflerent than property owner's address indicated above. ��] R. after 3 hrs.pumping_�� g.p.m. <br />$�•� WELL HEAD COMPLETION � �-� � <br />�� ,�[7 Pitless adapter manufacturer W h i�e w a t e r M�e��J���� <br /> ❑ Casing Protection ❑ 12 in.above qrade <br /> ❑ At-gratle(Environmental Wells and Borin gs ONLV) <br /> GROUTING INFORMATION <br /> Well grouted? :�i� Yes ❑ No <br /> GEOLOGI AL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement �1 eentoni�e ❑ Concrete ❑ High Solids eentonite <br /> MATERIAL from._�j_�to�ft. _�_ ❑ yds.JO bags <br />.,. tUt1 S �1 black lTl��l• Q � irom to fl. ❑ yds. ❑ bags <br /> from to fl. ❑ yds. ❑ bags <br />�� NEAREST KNOWN SOUFCE OF CONTAMINATION <br /> �Zc�ll l:rown iQECi. � Y7 �� feet 7w directionS�YT@1 �31�e <br /> Well disinfected upon completion? v Yes ❑ No <br /> �la� �111� meQ• 17 6� PUMP �I1 ZI gT <br /> ❑ Not installed Date installed <br /> sanct & yravel bi'Oii12 1Ii2C�. 6� 1�1 Manutacturer'sname __ S�.d—RYt@ ���� <br /> � Model number S 1��� HP�Volts �'`�V <br /> Length of drop pipe_ t� ft. Capacity �0 g.p.m. �r <br /> Pressure Tank Capacity z 5 v <br /> Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �No <br /> VARIANCE <br /> Was a vanance 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,E EVATION,SOURCE OF DATA,etC. The information contained in this repoA is true to the best of my knowledge. <br /> R.E.S. �ell DrillirY� 27276 <br />���� Licensee Busin s Name^, Lic.oi Reg.N . <br /> �':����--�.�'� � /3 ; � <br /> ' Authorized Representative Signature Date <br /> ko�ert E. S�odc�la, 3r. 5/13/5? <br /> Name ol Oriller Dafe <br /> �ocA�coPv 5 915 0 4 ME-01205-OS(Rev.1/95) <br />