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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 580409 <br /> Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section,No. Fraction WELL DEPTH(completed) rt Date Work Completed <br /> Orono <br /> F-96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 7 ❑ Cable Tool El Driven El Dug <br /> .,J�± 1C7x'ntK�i]7i {1. Win!? �.lCY1C3fl ❑ Auger ❑ Rotary ❑Jetted <br /> Show exact location of well in section grid with X'. Skil map of well location. ❑ <br /> 55356 3h ,,,i n,,,property lines, <br /> s and buildings. DRILLING FLUID y� <br /> N �lonl tf <br /> --ry USE ❑ Monitoring ❑ Heating/Cooling <br /> i [Y-Domestic <br /> { - El Community PWS ❑ Industry/Commercial <br /> ,. ❑ Irrigation ❑ Noncommunity i i i i X y PWS 1-1 Remedial <br /> W E T ❑ Test Well ❑ Dewatering ❑ <br /> -� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> '/z Mae ❑ Steel ❑ Threaded ❑ Welded <br /> C�rPlastic ❑ <br /> s <br /> Fi Mile <br /> CASING DIAMETER WEI <br /> PROPERTY OWNER'S NAME 268 . �� ��" <br /> " in.to__ ft. lbs./ft. in.to ft. <br /> 'IA srry hicen Ccs anv <br /> in.to ft. lbs./ft. "iq jj <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> s Berkshire SCREEN ==Fr4 ngr,A OPEN HOLE <br /> ��rt;4 $ex'►C.:,�]1.rE.' LF.ai2� <br /> Plyt. - Make from ft.to ft. <br /> I"x °uet..t'j Mn. �14�� <br /> Type St 1'a i�'��.. :7 Steel Diam. i <br /> ; <br /> Slot/Gauze '"r _Length fi 411 <br /> Set between 269 ft.and 7 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 12= ft. a below ❑ above land surface Date measured 5-1 15-96 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 1,6 ft. after hrs.pumping 3€. g.p.m. <br /> WELL HEAD COMPLETION <br /> El,fitless adapter manufacturer llt'Pilt'c E'L Model <br /> ❑ Casing Protection .L£] 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 3I Yes ❑ No <br /> HARDNESS OF Grout Material El Neat cement ElBentoni ❑ Concrete ❑ High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from L= to t' ft. L ❑ yds. [Xbags <br /> from to ft. ❑ yds. ❑ bags <br /> E 1 <br /> Clay Yellow 1. 4 ' from to ft. ❑ yds. ❑ bags <br /> NEARES KNOWN SOURCE OF CONTAMINATION / <br /> Clay C :i 4C 1 31,. .[ feet ��(,Ir f^ direction . %'� type <br /> r+,.. Well disinfected upon completion? ❑les El No <br /> Clay-Gravel Grey 5 138 3 7 V' PUMP t <br /> El Not installed Date installed 6-1 t1-96 <br /> Manufacturer's name i' & W <br /> S , Cldy, ('ra\el Brown �_ 17E' 2 _i n. , _ ,� <br /> Model number C HP Volts <br /> Length of drop pipe �t I ft. Capacity 19 g.p.m. <br /> Clay 2151 GF! Pressure Tank Capacity (E-AIEHY'ler C-Al,;t <br /> Type: [),,Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> Gravel <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes U. <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes IX No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,it 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 /> ITEM 631CCOLA WWUA, DRII.IJNG CCS., INC:. 27 1-i <br /> ' <br /> /Licensee Business Name LIC.or Reg.No. <br /> 5—15-96 <br /> ` Authorized Representative Signature Date <br /> Fri Lerr_3y :')-15-96 <br /> 1580409 � <br /> Name o/Driller Date <br /> LOCAL COPY HE-01205-05(Rev.1/95) <br />