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WELL LOC*TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounyrNam(; WELL AND BORING RECORD Aj -, 3 <br /> Fiet�nepi.n Minnesota Statutes Chapter 1031 � 1 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n <br /> Orono, 11-1 _-i l)`f �s—ty;i+ii � 16�` �--16-96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 146 'T'Csr'Ikaula Roau Grc)rKA, Fin. 553 56 ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ❑,Rotary 71 Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _____ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID mper.,{. <br /> N Bto a t e <br /> USE El Monitoring ❑ Heating/Cooling <br /> i F*Domestic ❑ Community PWS <br /> ❑ Industry/Commercial <br /> EI Irrigation <br /> 71 Noncommunity PWS -1 Remedial <br /> we .'i ❑ Test Well <br /> i T •�. ❑ Dewatering ❑ <br /> i i �` I ---•• CASING Drive Shoe? O Yes [-Dflo HOLE DIAM. <br /> 2Miie <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> d:Plastic ❑ <br /> s '\ <br /> �1 Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to1�{ ft. 1.0 lbs./ft. i 3i' <br /> Ri & A':ry Caldwell in.to ft. lbs./ft. 6 1;�,�, 18rj'I. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make � 3 'f from ft.to ft. <br /> Type • ..ain `ss steel Diam. -a <br /> Slot/Gauze 10/10 Length 9 1 _ <br /> tl <br /> Set between I Bill ft.and leg . FITTINGS: L X .SilN <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME ___=__` ft.X below ❑ above land surface Date measured B--16-96 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailingaddress if different than properly owner's address indicated above. ft. after hrs.pumping '�� �'"� m. <br /> P P YP P 9 9 P <br /> WELL HEAD COMPLETION �.t[7� <br /> E Pitless adapter manufacturer nn1`-AeW&_te1 Model <br /> ❑ Casing Protection ❑N2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 6 Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑Oentoni ❑ Concrete Q FPO Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO t i � <br /> from to ft. ❑ yds. bags <br /> from to ft. ❑ yds. ❑ bags <br /> clay yell(-&, S l 118, from to ft. ❑ yds. ❑ bags <br /> VEAREST KNOWN SOURCE OF CONTAMINATION j <br /> 1W. 'SC-U-i Grey M 118 17 ;- feet direction `-r' type <br /> Well disinfected upon completion? 9 Yes ❑ No _ <br /> Silty Clay Grey S 1-it) 17 tO <br /> PUMP <br /> El Not installed Date installed <br /> �' ���'�� <br /> sarxi 111 LXe0 M 17 8 1 18 Manufacturer's name Wyla M}I ers rAILT <br /> Model number HP Volts <br /> Length of drop pipe well ft. Capacity g.p.m <br /> ell . <br /> Pressure Tank Capacity mate 6+ 9 <br /> Type: Ci�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS y, <br /> Does property have any not in use and not sealed well(s)? El Yes Li I <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑"No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 /> UuN S:.'L OLN IKU DRILLING ING k-`). , INIC. 271 i L <br /> Licensee Busin Name Lic.or Reg.No. <br /> _f 6--16-96 <br /> Authorized Representative Signature Date <br /> Chuck A-Axle 8_16-96 <br /> Name of Driller Date <br /> '_OCAL-COPY 158647 3 HE-01205-05(Rev.1/95) <br />