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, _ , � ��, <br /> �,� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 615 2 �. 3 <br /> ��yp�rj@�}''j,A Minnesota Statutes Chapter f03! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �L°OCIq 1l� �� �J w ,Sil�,�. t�11' v. y�? n ll��}��d <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> .i5ii�i id3 Sf t$�B �i+�+ud C�roAa 'S53 rt ❑ cab�e Too� ❑ Driven r� 0�9 <br /> Y ❑ Auger O�otary ❑ Jetted <br /> Show exact location of well in section grid with"X". �� Sketch map of well location. ❑ .__ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES [�JO <br /> N <br /> � , � , >C ��ter FROM n �o h. <br /> -,- -,- -,-- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i �Qomestic ❑ Communit PWS <br /> -�- -�- -�- -�- ❑ Irrigation Y ❑ Industry/Commercial <br />. i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w E T ❑ Test Well <br /> i � i i ❑ Dewatering ❑ <br /> i -, i _r 'ZIM.ie CASING DriveShoe? ❑ Yes ❑ No HOLEDIAM. ��. <br /> _i_ _ �_ _i _ _i_ I � Steel ❑ Threaded ❑ Welded ""'r <br /> � � � � � fr'" � PIBS[iC ❑ <br /> S � I <br /> �1 Mile-� <br /> � • CASING DIAMETER WEIGNT <br /> PROPERTY OWNER'S NAME � in.to��ft. �`CY"tl Ibs./ft. �in.to�Ot. <br /> ��y �� � t __ in.to tt. IbsJft. �.3r in.to__�t. <br /> -�i <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. __in.to ft. <br /> SCREEN_ OPEN HOLE <br /> Make �a�'�'j�_ from ft.to ft. <br /> Type pU�[` Diam._�a <br /> SIoUGauze_ ?Ll Length 7 t <br /> Set between �._j�ft.and �� R. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME •$aQ ft. �below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. L��ft. after ,3 hrs.pumping Si%t g.p.m. _ <br /> WELL HEAD COMPLETION S <br /> �titlessadaptermanufacturer �rii�r��atr�� Model �J' �5�'4 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? C,f�'es ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement �Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from��to_�_ft. � Cj�yds. ❑ bags <br /> from_________to ft. ❑ yds. ❑ bags <br /> �`�a ��OWj1 �t�'�• Y j� from _to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> g�,��y Cj�� jyju�,a ��st1. ,Y;; %'y ',�" � feet _ I's�t1 directiont3�."MiEeC j3lii�t� <br /> / Well disinfected upon completion? �Yes ❑ No <br /> SC3AC3. � �T.AV�Cs'.L �l�X PlBGTi�J PUMP <br /> ❑ Not installed Date installed j.����!�� <br /> Manufacturer'sname �J�.d����`rt2 <br /> Model number HP .�. Z Volts J�..'jV <br /> Length of drop pipe 'b� ft. Capacity l� g.p.m. <br /> Type: �i.Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes I]jjJo � <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 /> �cs w�all �rillin�} 2727�i <br /> Licensee Business Name Lic.or Reg.No. <br /> �;. ? - <br /> Authonzed�Representativ nature �"��' Dat <br /> btoic�ert �. �tociala: �r. i.tl�j/�t� <br /> Name ol Driller HE 01205-06(Rev.9/97) <br /> LOCAL COPY � � �j�1 � <br />� <br />