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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName . WELL AND BORING RECORD 6 2 4 9 3 5 <br /> Hennepi n Minnesota Statutes Chapter 1037 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �rano 117 23 45 ,,. ,, ,,, 1Ifl� � 6-23-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRI�LING METHOD <br /> C ,a ❑ Cable Tool ❑ Driven ❑ Dug <br /> �JS ���.'�►f�� ��au Orono, �• ❑ Auger �1 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. DRtLLING FLUID WELL HYDROFRACTURED? ❑YESX[7 NO <br /> " Bentintbe <br /> , , , , } FROM n:co n. <br /> -,- -;- - - -,- ��t�,4 <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i �1 Domestic <br /> �_ _�_ _�_ _i_ ❑ Communiry PWS ❑ Industry/Commercial <br /> i � i i � ❑ Irrigation ❑ Noncommunit PWS <br /> w E T ❑ Environ.Bore Hole Y ❑ Remedial <br /> i i i � ❑ Dewatering ❑ <br /> i i r i �/ZIM;ia CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> - _i_ _ i_ _i _ _i_ ❑ Steel ❑ Threaded ❑ Welded <br /> i l i i <br /> 1 x] Plastic ❑ C�7 s�n <br /> �1 Mile� h4 i f} <br /> '�"� { �t�-+� �O CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME '4 in.to �02 ft. 2�05 Ibs./ft. � in.to 31 �ft. <br /> P��gy Peterson in.to ft. Ibs./ft. �in.t�j�ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to R. <br /> SCREEN OPEN HOLE <br /> Make JD n�1 from ft.to ft. <br /> Type .�Stgirll��$ Steei Diam. �M <br /> SlotlGauze_ ��1� Length �� 9 � <br /> Set between 1�Z ft.and � �ff ft. FITTINGS: 2 x x J�~ fIT� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 3� R.�[below ❑ above land surface Date measured�,=_�3�1�� <br /> pe��y Peterson <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. �9 n. aeer 1 hrs.pumping �� �� T g.p.m. <br /> %Dave Peterson yWELLHEADCOMPLETION <br /> ' G�1 C tF7 Pitless adapter manufacturer Wh i t ewa t er Model <br /> 2V 6 J r'Qx s t ree t ❑ Casing Protection X7 12 in.above grade <br /> Q�C}T10� �• 55 391 ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> _ Well grouted? C�(Yes ❑ No y <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete LT High Solids Bentonite <br /> MATERIAL <br /> from � to�ft. 2.5 ❑ yds.�7 bags <br /> from to ft. ❑ yds. ❑ bags <br /> TO 80f 1 BiaCk fl� 5� from co n. ❑ ya5. ❑ bags <br /> ' NEA T OV�N SOURCE OF CON�7/q/N�JN,ATIIO�N <br /> -� 'V-(/V• direction <br /> ; Ciay Y@110W M 5� I$* feet � �� ryPe <br /> Well disinfected upon completion? ❑ Yes ❑ No �� <br /> Clay (Rocks) Grey M 18� 95' PUMP <br /> ❑ Not installed Date installed 7�$��� <br /> Water Sand Grey S 95• I 1 fl* Manufacturer's name Red Ja�cket <br /> Model number Q 1`S I S�7 HP 3 4 vons 2 30 <br /> Length of drop pipe V� R. Capacity �` g.p.m. <br /> Type:`d Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS �/ <br /> Does property have any not in use and not sealed well(s)? ❑ Yes *E] No <br /> VARIANCE <br /> ! � Was a variance granted from the MDH for this well? ❑ Yes 1J No 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 /> y <br /> D�N STODC?LA �tELL DRILLIWG C0. , INC. <br /> Licensee Busines a Lic.or Reg.No. Z'�1 T 2 <br /> .=-- 7-I2-99 <br /> Authorized ReprEsentative Signature Date <br /> Chuck Moor� 6-23-9g <br /> Name of Driller Date <br /> LOCAL COPY 6 �4 9 3 5 HE-01205-06(Rev.7/98) <br />