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MINNE <br /> MINNE TA <br /> SOTA UNIQUE WELL NO. <br /> ' WELL LOCATION SO DEPART ENT OF HEALTH <br /> - CountyName WELL AND ¢O ING RECORD 6 2� 9� 5 � <br /> Heanepin Minnesota$tatute Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction W�LL DE TH(completed) Date Work Completed <br /> �rono 217 23 06 ,,, ,, ,. , 26S' tt 7-1 g-- <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number RILLIN METHOD <br /> 4461 Ba 81de �038 O�Cocio. Mri. 5356 CableTool t❑G Driven ❑ Dug <br /> Y Auger ai Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. � <br /> Showing property lines, <br /> � ro s and,buildings. ILLIN FLUID WELL HYDROFRACTURED? ❑YES �NO <br /> N � <br /> �, _i_ _ i_ _I _ _I_ f tOIIf L@ FROM __ft.to n. <br /> i i i i �---'` <br /> U E ❑ Monitoring CI Heating/Cooling <br /> i i i i � . Domestic <br /> _i_ _�_ _�_ _i_ � ❑ Community PWS ❑ Industry/Commercial <br /> i i i i Irrigation ❑ Noncommunity PWS ❑ Remedial <br /> w e � �����Environ.Bore Hole <br /> � i i i X ❑ Dewatering ❑ <br /> -r -�- -r- -r T <br /> i i i ' +/zMie ��t(� C SING � Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _� i i i_ � Steel ❑ Threaded ❑ Welded <br /> _ _i_ _ _ _i <br /> Plastic ❑ <br /> S <br /> �-1 Mile-� . <br /> CASING ��IAMETER WEIGHT <br /> PROPERTY OWNER'S NAME in.to 252 n. SI}��Z1 IbsJft. �.�0 h. <br /> Gabriel Jabbous �n.to_ ft. Ibs/ft. in.to2fiSft� <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br />� SCREEN OPEN HOLE <br /> M ke Jothason from R.to ft. <br /> p�r- T�pe e$igleg� st.�ne.1 Dia p <br /> SI�VGau 0�8 0�8 OZ V Length ��' �+ � <br /> Set betw n ��_�'�ft.andZ��f ft. FITTINGS: <br /> � S ATIC ATER LEVEL - <br /> WELL OWNER'S NAME � ft. �below ❑ above land surface Date measured �7 � <br /> PWM�PfIN LEVEL(below land surface) <br /> 'Well owner's mailing address if different than property owner's address indicated above. 6� f ft. aRer 3 hrs.pumping ZQ g.p.m. <br /> �.. <br /> a� `~ � LL HE D COMPLETION �y�. <br /> Pitless daptermanufacturer �u�te�at�� Model <br /> ❑ Casing Protection �12 in.above grade <br /> ❑ At-gra (Environmental Wells and Borings ONLY) <br /> G OUTI INFORMATION <br /> Well routed? �1 Yes ❑ No <br /> HARDNESS OF Grou Material ❑ Neat cement ❑ eentonite ❑ Concrete X] gh So�ids Bentoynite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO /� �_ ❑ yds.4 bags <br /> from � to 3 V ft. <br /> Ciay Gr�y S O� iQo from to_ ft. ❑ yds. ❑ bags <br /> from to fl. ❑ yds. ❑ bags <br /> �s 1 N AR �yN SOURCE OF CO I/��pT ION y,v✓: ` <br />: Sand a�� ..5 �0� 1�O feet �y `-� direction��• f r� type <br /> WBII disinf cted upon completion? Ia.Yes ❑ No <br /> Siit Grey S 180 252 P 'MP <br /> ❑ Not in alled Date installed 1�19�'� <br /> Sand-Gravel Tan S 252 265 Gcsulds �' <br /> M�nufactu r's name <br /> Madel nu er SJF2021 L HP 2 Volts 2�0 <br /> t �f <br /> Le gth of op pipe Z 6 B ft. Capacity `� g.p.m. <br /> Ty e: t? ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABpNDO ED WELLS <br /> Dogs prop�rty have any not in use and not sealed well(s)? ❑ Yes �No <br /> VA IANC ' <br /> Was a vari ce granted from the MDH for this well? ❑ Yes �No TN# <br /> 5 <br /> W�LL CO TRACTOR CERTIFICATION <br /> Use a second sheet,if needed ThiS well w s drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The inform tion contained in this report is true to the best oi my knowledge. <br /> DON TODOI�A wIELL DRILLING C0. , INC. <br /> Licensee Business N el� Lic.or Reg.No. �f^/i 9 2 <br /> i! ! <br /> 1-3 <br /> Author¢ed Repr ative Signature Date <br /> Fred Leiby 7-16-00 <br /> I Name of Driller HE 01205-06(Rev.7/98) <br /> LOCAL COPY 6�Q.9 4 5 <br />