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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD rte, <br /> Minnesota Statutes,Chapter 1031 7 19 0 'st wk`" <br /> Township Name rTownshipNo. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Oman27 23 48 y, ,/, % 161 ft. 12-6-04 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> ❑Auger otary ❑Jetted <br /> House Number,yS,,tr�ee�t Name,City,and Zip <br /> �,Code of.Well Locatgioent jor Fire Number ❑ <br /> 1335 onkm AdOb 553% DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Show exact location of_well in section grid with"X. Sketc AuZ of well location. FROM ft.TO ft. <br /> o g property lines, <br /> Nro ds and buildings USE <br /> ❑Monitoring ❑Heating/Cooling <br /> /Domestic LlEnviron.Bore Hole L]Industry/Commercial <br /> -1-- <br /> ` ❑Noncommunity PWS ❑Irrigation ❑Remedial <br /> �+ ❑Community PWS ❑Dewatering ❑ <br /> --'-----'----- -----F-- • <br /> CASING HOLE DIAM. <br /> w � � e <br /> '' Drive Shoe? ❑Yes y��LrcJ No <br /> ;___-- ---__ El Steel ❑Threaded ❑ elded <br /> 1T Mile lastic ❑ <br /> 1 CASING DIAMETER WEIGHT <br /> y in.to 153 ft. 2.(Albs./ft. n.to rift. <br /> 1 Mile <br /> in.to ft. lbs./ft. in.tori ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME - in.to ft. lbs./ft. in.to ft. <br /> Steiner & KWpelm l SCREEN OPEN HOLE <br /> Property owner's mailing address <br /> if different than well location address indicated above. Make johmm FROM ft. TO ft. <br /> 18340 Minnetonka Blvd Type stain—lin Dia <br /> Wayzata SIN 55391 Slot/Gauze 0010 Length 4 + 41 <br /> Set between ft.and__I_J_I_ft. FITTINGS„ W/ <br /> STATIC WATER LEVEL �f <br /> % ft. . below [_]above land surface Date measured 12-6-04 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 150 ft.after 2 hrs.pumping 60—_ -9-p.m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturerls ;�12 <br /> F1Casing Protection in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes ❑No <br /> Grout material ❑Neat cement ❑Bentonite ❑Concre High Solids Bentonite <br /> from to 0 ft. _- 3 ❑yds.?<bags <br /> from to_ 53 ft. fj2� [_1bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF MATERIAL FROM TO from to ft. E]yds. L]bags <br /> NEAREST KNjjOWWNL`SOURCE OF CONTAMINATION <br /> !V feet ++ direction <br /> topsoil black acrft 0 $ <br /> Well disinfected upon completion Yes ❑No .;-A" <br /> PUMP <br /> ' <br /> cla brown soft <br /> 4 12 ❑Not installed Date installed ea/ v <br /> f <br /> clay soft 12 1" Manufacturer's name a" <br /> 1 1 1!r 4'Q Model number HP Volts <br /> r$VeI broitm soft 148 162 1 Length of drop pipe y ft. Capacity g.p.m. <br /> Type: ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANOONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes XNo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes XNo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge.knowledge. �ry <br /> Use a second sheet,it needed DM Sti la IM �-lim W.>*u. 2l 172 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. WLi .k <br /> Licensee Business Name Lic.or Reg.No. <br /> G5, <br /> ore =presentative S(gPaKur= Date <br /> Chuck 1—bore <br /> LOCAL COPY 719809 <br /> Name of Driller' <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />