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. � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> - CountyName WELL AND BORING RECORD 6 2 4 9 6 2 � <br /> Minnesota Statutes Chapter f 03! <br /> � <br /> Township am Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 2I7 23 �J5 ,,. ,. ,. I1Q � 8-9-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DFiILLING METHOD <br /> 3 G t n B$ S A 1 Q n a fl�ofl� ❑ Cable Tool ❑ Driven ❑ Dug <br /> J 1 V 1C! n.l�„t ❑ Auger �otary ❑ Jetted <br /> Show exact location of well in section grid with" Sketch map of well location. ❑ <br /> Showing property lines, <br /> 1 roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES <br /> N �v <br /> � benLonite FROM h.�o h. <br /> _� � � �_ `�...� <br /> ; -,- -;- -, , <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i omestic <br /> _i_ _�_ _�_ _i_ y � ❑ Community PWS ❑ Industry/Commercial <br /> i � � i �.. �.,. ❑ rrigation ❑ Noncommunit PWS <br /> w e� � ❑ Environ.Bore Hole Y ❑ Remedial <br /> i i i i ❑ Dewatering ❑ <br /> i -, -r i ,/ZM.ia CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _i_ _i_ _i_ ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> 1 �astic ❑ <br /> �-1M,le� dl W�t-L <br /> CASIN`G DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �t in.to 102 ft. 2��S Ibs./ft. 8 <br /> in.to <br /> R.ober t C ra3.u Ao��s ��.to n. �bs.�h. ���.to <br /> _ Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R. in.to ft. <br /> 2�U7S BL�Z3CI�LtS Rd SCREE� _ OPENHOLE <br /> Shore�ood, �'�� 5533I Make Q"�� ! from ft.to R. <br /> Type ��$ i11C2i7S �L�$1 Diam. <br /> SIoUGauze �O1,Q Length�}� ♦ �}� <br /> Setbetween ��ft.and_}_�a__ft. FITTINGS: 9�M_�����Yp <br /> " STAT ATER LEVEL <br /> WELL OWNER'S NAME �� ft.�low ❑ above land surface Date measured �_�_� <br /> PUMPI�J,€VEL(below land surface1 � �� <br /> Well owner's mailing address if different than property owner's address indicated above. tS ft. after �'• hrs.pumping g.p.m. <br /> �L HEAD COMPLETION L4 <br /> Pitless adapter manufacturer �[l1 t��a t��Model <br /> ❑ Casing Protection L�in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �es ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete �gh Solids eentonite <br /> MATERIAL from�_to_�__ft. �_ ❑ yds�ags <br /> Clay yello�a soft 0 28 '`�"'�—`���" natur�� �������45 � <br /> from to ft. ❑ yds. ❑ bags <br /> _ �lay �ra� SQl� "�� 85 NEARES (N�NSOUReetOFCr��/��Ti' direction{L��type <br /> Well disinfected upon completion? ❑ Yes ❑ No " �"� <br /> Watersanc� grsy soft 85 110 P�MP �:�- TEsTE"4 <br /> ❑ Not installed Date installed O�1 3�Q9 <br /> Manufacturer's name 8ed Ja�ice t <br /> Model number pl HP �s 5 Volt��� � <br /> Length of drop pipe U`� ft. Capacity g.p.m. <br /> Type:�ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes j�o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes .�Jo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Ik�n Stodo2� We1I Drillin� Cv. , INc. 717: <br /> Lice ee Busines ame� � Lic.or Reg.No. <br /> �._,..�� � i <br /> > .- �--- - 8-29-99 <br /> Authorized Repres ative Signature Date <br /> Chuck MQore 8-9-99 <br /> 6 2 4 9 6 2 Name ol Driller Date <br /> LOCAL COPY HE-01205-06(Hev.7/98) <br />