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MINNESOTA UNIQUE WELL <br /> WELD : BONG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD 79199_ <br /> 5 <br /> Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> orlow lie 23 31 I IN M q ft. <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> ❑Cable Tool Driven <br /> Longitude degrees minutes seconds ❑ <br /> E)Auger �lotary <br /> House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other <br /> 125 Tardam No Ocow DRILLING FLUID WELL HYDROFRACTURED? 71 Yes UMO <br /> Show exact location of well/boring in section grid tith"X:' Sketch map of well/boring location. bentonite From ft.To ft. <br /> s Old} Showing property lines, <br /> N roads,buildings,and direction. USE Domestic ❑Monitoring ❑Heating/Cooling <br /> ;___ __i_____________ \ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> 1 ❑Community PWS ❑Irrigation ❑Remedial <br /> _--_-a____ -----:.- ❑Elevator ❑Dewatering ❑ <br /> W ET CASING MATERIAL Drive Shoe? ❑Yes XNo HOLE DIAM. <br /> r <br /> 'h Mile rJ— — Threaded gilded <br /> ❑Steel T W <br /> I + i ]Plastic ❑ <br /> CASING <br /> s Diameter Weight Specifications <br /> 1Mile 1v�V",1 n.To 172 ft. lbs./ft. in.To �ft <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.T.180 ft <br /> Masterpiece I1 n.To ft. lbs./ft. n.To ft <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> 127 E Cty Rd C Make From ft. To ft. <br /> Little Cie MN 55117 Type a atl Diam. Z <br /> Slot/Gauze Len*f 49 <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL Measured from <br /> j so ft.;XBelow ❑Above land surface Date measured 04 <br /> ti WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> IL60 ft.after 3 hrs.pumping 25 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer Model <br /> ❑Casing protection �W12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br />' Material I14>Glt romTo #(�_ft. 3 ❑Yds. Fags <br /> Material fl$tl2Mt c To 1, _ft. ❑Yds. [_1 Bags <br /> HARDNESS OF Material From To ft. [I Yds. El Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags <br /> yellow/ NEAREST KNOWN SOURCE OF CONTAMINATION <br /> UY <br /> Abrown its 0 13 <br /> 7 feet direction _x type <br /> q� <br /> Well disinfected upon completion? KYes El No <br /> el" am soft 13 132 PUMP <br /> L]Not installed Date installed 10-17—12 <br /> smd 'al" ad meditm 132 180 Manufacturer's name Sicb,l Ew <br /> Model Number t HP 11 3f1 <br /> .!1 Volts 2 <br /> Length of drop pipe 126 ft. Capacity _ 9-p.m <br /> Type:VSubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes yNo 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. <br /> Use a second sheet,it needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodola Stell killing Co., Inc. 1691 <br /> Licensee Busmes ame i- Lic.or Reg.No. <br /> 10-25'-12 <br /> Kertill presentativ 'nature Certified Rep.No. Date <br /> LOCAL COPY 7 919 9 5 Name of Driller Ryan Ned"mcd <br /> 1C 140-0020 <br /> HE-01205-13(Rev.11/10) - <br />