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� . .�. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 615 5 6 9 � <br /> Hen�epin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �rono 11$ 23 31 ,,. ,. ,. ��5 � �-22-98 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> �i7�F� t�A ���'E �E� �r�11� 553 9 ❑ CableTool ❑ Driven ❑ Dug <br /> f ❑ Auger �i, 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 O <br /> i i N i i 17�'jry.�()f'��,��.s FROM ft.to ft. <br /> _i_ _�_ _i_ _i_ <br /> USE _�[ � Monitoring ❑ Heating/Cooling <br /> i i i i pFUomestic ❑ Communi PWS <br /> _i_ _�_ _�._ _i_ ❑ Irrigation � ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w e� ❑ Test Well <br /> i � i � ❑ Dewatering ❑ <br /> i i r i '/ZM.ie y ���� CASING Drive Shoe? �/es ❑ No - HOLE DIAM. <br /> _, , _, _ _,_ � •� 1�Steel �/Threaded ❑ Welded <br /> i -i- i i <br /> ❑ Plastic ❑ K <br /> S { } /y� <br /> �-1 Mile-� A`� ���� y <br /> f Fr CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME _�_in.to�R. �� Ibs./ft. �i _in.to <br /> �}�(�i{i �(}(� in.to ft. Ibs./R. /�t;in.to <br /> ��F <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. �� C <br /> 1 <br /> SCREEN OPEN HOL/E <br /> Make from Z'�f� ft.to �S�ft. <br /> Type �j�j _ Diam. <br /> SIoUGauze _______Length <br /> Set behveen ft.and ft. FITTINGS: <br /> STATIC yWA9T+E�R LEVEL h <br /> WELL OWNER'S NAME 1 JG ft. elow ❑ above land surface Date measured �"�4" � <br /> PUMPING LEVEL(below land surface) /. <br /> Well owner's mailing address if different than property owner's address indicated above. ��� ft. after `t hrs.pumping 3fl g.p.m. <br /> WELL HEAD COMPLETION �mf t ewa t er <br /> �Pitless adapter manufacturer ```Mo///del <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 cement ❑ Bentonite ❑ Concrete igh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO g <br /> from 0 to 3� ft. � ❑ yds. �bags <br /> Topsoil hlack .g0�t {� � from_��_to�ft. �I$�131�i3� yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> L�� ellox $Q��. 9 `-� NEAREST KNOWN SOURCE OFCONTAMINATION l► � <br /> Y Y � `t ,C�_�"_�eet /�ja Q�JV direction;���T f�type <br /> � Well disinfected upon completion? �Yes ❑ No <br /> 3an� brown soft '*� U� pUMP p <br /> ❑ Notinstalled Dateinstalled ����w�o <br /> c:�.�� �r�y �o�c �o ��o Red J�cket <br /> Manufacturer's name <br /> Cl.ay/raeks �?L'QW(1 $Qf� 150 '�'L(� Modelnumber IQ{�CrN�1"`I��i1yr�P� Volts �3� <br /> Length of drop pipe i�S3 ft. Capacity g.p.m. <br /> 5`g�d tl.���� SD�t G2� 23t! Type: C�ubmersible C7 LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> C�a��ur�ve 1 C�i�r�� r�ed iuz� 230 240 Does property have any not in use and not sealed well(s)? O Yes �o <br /> VARIANCE <br /> Sh��� vr�(,a�s� �(�£t 2G0 2(�5 Was a variance granted from the MDH for this well? ❑ Yes C�CNo <br /> y WELL CONTRACTOR CERTIFICATION <br /> LimP s e on�,se a second 9ri���Eoi; �ed ium 2�� 2�tJ This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725 � <br /> REMARKS,ELEVATION,SOURCE O , . The information contained in this report is true to the best of my knowledge. <br /> l}on Stodola �ell I�ri27.in�; Cv. ,� Tnc. 2 I72 <br /> Licensee Business Na �,Lic.or Reg.No. <br /> uthorized Representat" Signature Date~ <br /> Chuck t�oote 5-22-98 <br /> ��5� � g Name of Driller Date <br /> LOCAL COPY HE-07205-06(Rev.9/97) <br />� <br />