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MINNESOTA UNIQUE WELL <br /> CLL OR ITORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORDHemep7 7 O O®,. <br /> in Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Oruro 118 23 33 8W Sid SE,, 140 n 2_A) Y <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> Auger [ otary [_1 Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number 0 <br /> 2760 Waterton Rd Ottxio 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes 5k4Qo <br /> Show exact location of well/boring in section grid w Sketch map of well/boring location. becitOnite From ft.To ft. <br /> 4 Showing property lines, <br /> N ) roads,buildings,and direction. USE <br /> 'Domestic ❑Monitoring ❑Heating/Cooling <br /> ---------- __ --------- ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> Elevator Dewatering ❑ <br /> w E t_, CASING MATERIAL Drive Shoe? ❑Yes [eo HOLE DIAM. <br /> C G <br /> 'h Mile <br /> Threaded Welded <br /> 1 J Steel ❑T ❑ <br /> I J�'qe------ <br /> ,*Plastic ❑ <br /> --- - <br /> CASING <br /> S Diameter Weight Specifications <br /> —1 Mile _5.. '.i.. -*_ _:�-'--s�;`•.- .A. _4 in.to�2 ft. 1 A lbs./ft. 128M _�in.ta490—ft. <br /> ��(+�� ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.hilt/ ft. <br /> Fred, s�,�„_ in.to ft. lbs./ft. in.to ft. <br /> ['[!�l ski' SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> Make Johnow From ft. To ft. <br /> Type staroles- at? Dia . <br /> Slot/Gauze_ .010 Length 41 i V <br /> Setbetween ft.and ft. FITTING <br /> STATIC WATER AW <br /> M Measured from q <br /> 100 ft.[Kelow ❑Above land surface Date measured 2-''9-09 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 180 ft.after I.5 hrs.pumping 20 —9 p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION i- <br /> f(Pitless/adapter manufacturer i _1; _ :_ Model <br /> ❑Casing Protection A 12 in.above grade <br /> ❑At-grade(Environmental Well and Baring ONLY) F� <br /> GROUTING INFORMATION <br /> Well grouted les ❑No <br /> Grout materials ❑Neat cement [Aentonite ❑Concrete ❑Other <br /> From T.--M—ft. 4 E]Yds. [; ags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To182 ft.nain. ❑Bags <br /> MATERIAL <br /> From To ft. ❑Yds. ❑Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATI(�1 <br /> clay 0 16 %-� feet direction type <br /> Well disinfected upon completion? ,ees ❑No <br /> elav arw soft 16 PUMP <br /> ❑Not installed Date installed -� <br /> Manufacturer's name i <br /> Model Number HP Volts <br /> 178 <br /> Length of drop pipe L� ' ft. Capacity g.p.m. <br /> Type: ubmersible ❑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 o 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. <br /> The information contained in this report is true to the best of my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodala We11 DiftlUng Co,. Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> rtified Representative Signatur Certified Rep.No. Date <br /> Cho* Noom <br /> LOCAL COPY 770001 Name of Driller <br /> IC 140-0020 HE-01205-11(Rev.3/07) <br />