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� _ _ <br /> WELL LOCATION MINNESOTA DEPART ENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName ������,in WELL AND BOR NG RECORD � ��6 �2 <br /> Minnesota Statutes hapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEP H(completed) Date Work Completed <br /> t:�rc�n�� i 1 `,` 2� 3-;% i 81 " G-�-y"i <br /> �. �, �. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DFILLING ETHOD <br /> ��+�� �+�y�.l.�.'<� ��Ji�C1 Ctron�,MN. r F'J''y ❑ ableTool ❑ Driven ❑ Dug <br /> ` C7 uger O}{totary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ' ❑ <br /> � ert lines, �� <br /> �Q Y$;a� � oa s an D ILLING LUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> " �n c7nite <br /> i i i i FROM ft.to ft. <br /> _i _i_ _i_ _i_ <br /> US ❑ Monitoring ❑ Heating/Cooling <br /> i i i i �] omestic <br /> _i_ _�_ _�_ _i_ ❑ Community PWS ❑ Industry/Commercial <br /> i i � i , ❑ rrigation ❑ Noncommunity PWS ❑ Remedial <br /> ❑ est Well <br /> W i � i i E T ❑ Dewatering ❑ <br /> -r -�- -r- -r <br /> -_- � i i i ��ZM11e CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ i _i_ _i_ � � '�, ❑ teel ❑ Threaded ❑ Welded <br /> i i- i i <br /> � lastic ❑ <br /> S <br /> I--1 Mile-� <br /> CA ING D AMETER WEIGHT <br /> PROPERTY OWNER'S NAME ti. �I !c: SDR ! t � in7dj�' fts ' <br />� in.to ft. Ibs./ft. <br /> r+;FRI:'.ii. a7U�IC1��G12 in.to R. Ibs./n. �7 in�o�� t�. `� <br /> Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br />`�,, SCREEN . OPEN HOLE <br /> Ma e ������ ���-, from ft.to ft. <br /> �' -"� �' , .it C:11 . �c� :J�f��l � <br /> 3.{,... -�.,'s.,.a ` TY Diam. � <br /> SIo�Gauze f%- �� Length �i � <br /> �j � ��y"'�; SeNbetwee � !L. ft.and �}k�t. FITTINGS: " a <br /> f;,11 � <br /> " � STATIC T��L€VEL X <br /> WELL OWNER'S NAME _�ay:� L"� ft.II below ❑ above land surface Date measured �—�"�_� <br /> � PUMPING EVEL(below land surface) <br /> Well owner's mailin address if different than ro ert owneYs address indicated above. � ^ �' <br /> g p p y � 4 ! ft. after hrs.pumping .0� g.p.m. <br /> V1(E�L HEA COMPLETION <br /> C3''�itlessa aptermanufacturer `�h�-������del <br /> ❑ asing rotection C}j12 in.above grade <br /> ❑ t-grade(Environmental Wells and Borings ONLY) <br /> GROUTIN INFORMATION <br /> i <br /> Well g uted? CJ��Yes ❑ No <br /> HARDNESS OF Grout aterial ❑ Neat cemen C�Bentonita ❑ Concrete ffiy�p�Solids Benbnite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � J <br /> � from_�_to �� ft. '�"� ❑ yds.� bags <br /> from to ft. ❑ yds. ❑ bags <br /> �l�;y ��j��� il �� , j� from to ft. ❑ yds. ❑ bags <br /> NE REST N N SQURCE OF CO MINAT <br /> C1��= Grey S : � '� .�'o�,�a",�/ s� T'tG <br /> ;�j �(_i teet direction type <br /> Well,disinfe ed upon completion? C]�'es ❑ No <br /> S['3jIC3 GY�c�VG'�� PUMP L, �7 <br /> � "`4`Yl � -��-' •� i❑ Not inst Iled Date inst�lJe� 7��U �` <br /> N <br /> ManUfactur 's n�m�^� _ <br /> 7 <br /> ModBlnum r_�_�d�7 ► HP_�t�olts <br /> Length of dr p pipe ft. Capacity g.p.m. <br /> Type: LT5 bmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ � <br /> ABANDON D WELLS �t�� - <br /> Does prope have any not in use and not sealed well(s)? ❑ Yes L]'No <br /> VARI NCE <br /> � Was varia e granted from the MDH for this well? ❑ Yes C�No <br /> WE CON RACTOR CERTIFICATION <br /> Use a second sheet,if needed This well wa drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta The�forma n contained in this report is true to the best of my knowledge. <br /> C1C!N :i`iGBci�l� G�'E�,L i�RII3i:,I�� i.;C). , INC. <br /> Licensee Business me.�" Lic.or Reg.No. �(�1;> <br /> *� ,� <br /> ,..�i' `�.�- 9-5-9� <br /> Authorized Representative Signature Date <br /> � f'�x"c^C� I,�7�1:,�,r y...�_�7 <br /> Name of Driller HE 01205-D6(Rev.9/96) <br /> LOCAL CC2PY 5 � G b 5 2 <br />