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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Minnesota Statutes, Chapter 1031 705916 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) It Date Work Completed <br /> O 'k /. /. 184 <br /> GPS DRILLING METHOD <br /> LOCATIONLatitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool Driven ❑Dug <br /> ❑Auger �]Aiofary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number 171 <br /> 3310 Ikertmn Rd, Orma 55356 DRILLING FLUID WELL HYDROFRACTURED? [IYes <br /> o <br /> Show exact location of well in secti rid with"X". Sketch map of well location. bentonite FROM ft.TO ft. <br /> Showing property lines, <br /> N J•, roads and buildings USE ❑monitoring ❑Heating/Cooling <br /> omestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> Noncommunity PWS ❑Irrigati6n ❑Remedial <br /> ! ❑Community PWS ❑Dewatering ❑ <br /> w --------- E T CASING Drive Shoe? El Yes *No HOLE DAM. <br /> [-I El Threaded Ll welded <br /> Ile <br /> fa <br /> ' Miie �\ <br /> -lastic cEl <br /> ` 1 ? � CASING DIAMETER WEIGHT <br /> t Mile f 40—in.to 176 ft. 2.01 lbs./ft. 8—in.to-3aft. <br /> in.to ft. lbs./ft. I in.toll QL ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to ft. <br /> Boyer And Him SCREEN OPEN HOLE <br /> Propwttyowner's mailing address if diffrent than well location address indicated aboveJ�n. Make FROM ft. TO ft. <br /> 3435 Cty Rd 101,9 Type stainL`go al Diam. <br /> I it�1�t �� � SIoUGauze -0 0 Length « 0 <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL ! �t <br /> __ - -•� 78 ft. elow ❑above land surface Date measured 5-17-04 <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME "' Q <br /> I73 ft.after 2 hrs.pumping 60 g.p m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. Witless adapter manufacturer( �- U °t"t1�l� Abde1 <br /> Casing Protection ❑12 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 ❑Concrete Xigh Solids Bentonite <br /> from to 30 ft. 3 E]yds. �eags <br /> t �lt�t �,{, <br /> from 3'0 to 176 ft.1U1X1 f=. ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF <br /> MATERIAL FROM TO from to ft. [:1 yds. El bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> j feet — E. direction .'type <br /> Well disinfected upon completion YYes ❑No <br /> PUMP <br /> clay grAy soft 16 4 <br /> ❑Not installed Date installed _ �/V <br /> Manufacturer's name _ 7 v <br /> Model number HP e" Volts <br /> clay Qn i yr Length of drop pipe /,;)G ft. Capacity 9-P m. <br /> Type:K.bmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABAADONED 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 X0 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,if needed q +� <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. &M SCOdols Well Drilling Co., Inc. 27172 <br /> Licensee Business Name Lic.or Reg.No. <br /> r' a esentative Signature.. Date <br /> Gnirk-lb-nre <br /> LOCAL COPY 14 <br /> Q 5 91 6 Name of Driller <br /> HE-01205-0e(Rev.5/02) <br /> IC 140-0020 <br />