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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name <br /> WELL AND BORING RECORDftmpft 760620 " " <br /> Minnesota Statutes,Chapter 1037 <br /> Township Namehip No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> 0900 117 23 :moi,08 in W 108 h. <br /> Towns4-"-m <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds E]Cable Tool [_1 Driven [j Dug <br /> ❑Auger ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number �❑ - <br /> W Orem 553% DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Show exact location of well/boring in section grid th^X' Sketch map of well/boring location. MOW From ft.To ft. <br /> Showing property lines, <br /> ''. roads,buildings,and direction. USE g ❑Heating/Cooling <br /> n i N omestic ❑monitoring <br /> ' __L_____t__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> --'------------�-----`-- F]Elevator ❑Dewatering ❑ �`"' <br /> w f E T CASING MATERIAL Drive Shoe? ❑Yes j�o HOLE DIAM <br /> ' I ❑Steel ❑Threaded ❑Welded <br /> y <br /> h Mae �astic E J <br /> ; 1 - <br /> -T-- ---�-- ---'-- CASING <br /> s DiametQr 100 Weight 4j nJ Specification 8 30 <br /> —1 Miie in.to ft. IbS�./R. i+yL� n.toft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> n.to ft. lbs./ft. in.to ft. <br /> Property-owner's mailing address it different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> IBM �yy� Make From ft. To ft. <br /> 18340 371umC dU Blvd Type Diam. <br /> metas M 553% SIoUGauze Length <br /> Set between_ _ft.and1, Q ft. FITTINGS <br /> STATIC WATER LEVEL <br /> Measured from _gyp <br /> 45 ft.LYIfelow ❑Above land surface Date measured��R)O <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 1+5 <br /> 30 <br /> A7�J ft.after hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> LAtless/adapter manufacturerthitmater Model <br /> ❑Casing Protection [>w in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted ( "Fes ❑No <br /> Grout materials ❑Neat cement L_�dentonite ❑Concrete 7 Other <br /> 0y From__To ft. 3 ❑Yds. �ags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 30 From IM To �, _ tjL [_]Yds. [:]Bags <br /> MATERIAL <br /> From To ft. ❑Yds. ❑'Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> 0 911 7.5 C". <br /> feet ..1 direction <br /> Well disinfected upon completion? LVes ❑Nosaw 90 <br /> UMP <br /> 6-1 <br /> E]Not installed Date installed <br /> Manufacturer's name t, 2W <br /> Model Number HP 1.5 Volts <br /> Length of drop pipe 63 ft. Capacity g.p.m. <br /> Type:submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes L Qo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> Use a second sheet,if needed. The information contained in this report is true to the best of my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. . DM at a j,a j Wel• DrUlIng 0D*' Toe. <br /> 16" <br /> Licensee Business Name „* Lic.or Reg..No. <br /> 1?rli <br /> Ce d esen a igna r Certified Rep.No. Date <br /> CIMA <br /> LOCAL COPY � 760620 Name of Driller MOM <br /> IC 140-0020 HE-01205-11(Rev.3/07) <br />