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,,. <br /> __.,.,.� .. .. <br /> WELL!_flCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> � CountyName ` . ' WELL AND BORING RECORD 5 � 7 %� 4 .�� <br /> Kenne�i n Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � <br /> Orona I17 23 OS ,,. ,: ,. 105 k 9-21-98 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 3II 50 Bays i de R�� �.t�Z]� �5�� ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ❑ Rotary ❑ 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 ❑NO <br /> N <br /> _� � � �_ 41L`��' n�+ttiral FROM h.�o h. <br /> ; -,- -;- -, <br /> USE ❑ Monitoring ❑ Hea�ing/Cooling <br /> i i i i ❑ Domestic <br /> _i_ _�_ _�_ _i_ X ❑ Community PWS ❑ Industry/Commercial <br /> i i � i ❑ Irrigation ❑ Noncommunit PWS <br /> w e� ❑ Test Well y ❑ Remedial <br /> i i i i ❑ Dewatering ❑ <br /> i -, i r �/2M.ia CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ i_ _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> ❑ Plastic ❑ <br /> s <br />"�"� �-1 Mile� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME __ � in.to__gZ ft. ��� Ibs./ft. $in.to�JSJt. <br /> Paul/Raren r�adsan in.to ft. Ibs./ft. (�iin.to��ft. <br /> �� <br /> Property owner's mailing address if different than well location address indicated above. _in.to R. Ibs./ft. in.to tt. <br /> 320 Geor�i:. ��`tn!! SCREE OPEN HOLE <br />�: Golden V�2Iey, �IN 5S4Z7 Make o n�an from nto h. <br /> Type sta3nless S�l�� Diam. <br /> SIoUGauze ���� Length �� ; � t• <br /> " Set between A�ft.and 9�►G ft. FITTINGS: <br /> 7 i�7� <br /> STATIC��TER LEVEL <br /> WELL OWNER'S NAME ft. ❑ below ❑ above land surface Date measured �'1;_g <br /> PUMPING LEyF,�(below land surface) ry <br /> Well owners mailing address if different than property owner's address indicated above. i�t-� k. after L hrs.pumping 40 g.p.m. <br /> WELL HEAD COMPLETION i� <br /> ❑ Pitless adapter manufacturer Edi13 t Q WS t p[' Model . <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑ Yes ❑ No �. � �-� <br /> HARDNESS OF Grout Material ❑ Neat cem t ❑ Bent i e ❑ Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �{' �� c 9 <br /> from V to ft. 2��7 ❑ yds. ❑ bags <br /> ��'. 1����1 lack $Qf[ � ,[4 from�to_g_Zft. �'j$�iJ.�r3Z_ ❑ yds. ❑ bags <br />, from to ft. ❑ yds. ❑ bags <br /> 1{a� dra� e�1�3� � �!y NEARE T NOWNS CEOFCONTAMINATI� l7r�� <br /> � // / t: <br /> � et __L�3� direction�„�3rT_t���type <br /> Well disinfected upon completion? ❑ Yes ❑ No w <br /> 1$Y k �;ray soft �� �0 PUMP t <br /> ❑ Not installed ate i stalle L������ <br /> a�+�.r.sand �ray oft 9� lE}S �ec� .�ac�;et <br /> ManufactureYs qa <br /> i Q <br /> Model number HP � Volts <br /> 2 .� <br /> Length of drop pipe ft. Capacity 4 '� g.p.m. <br /> Type: C�Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ "- <br /> ABANDONED WEL�S <br /> Does property have any not in use and not sealed well(s)? ❑ Yes C�'No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes f�^No <br /> WELL CONTRACTOR CERTIFICATION �� <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. �� <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> �)on St4dala We2I Drillin�, �o. , Inc . �7Z <br /> � Licens Busine Name �, Lic.or Reg.No. <br /> ��-�=,f�L.i�� .���� .�_-...�.� I I-12— �s <br /> '� Authonzed Representative Signature Date <br /> '�, e�1i��$�`-�i O t'3��' ��1�."��3 <br /> Name ol Driller HE 01205-06(Rev.9/96) <br /> LGCAL Cc�PY 5 9 7 2 41 <br />