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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD Minnesota Statutes,chapter 1031 0 0 <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> a ft. <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger ❑Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other :'1 <br /> DRILLING FLUID "':WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling <br /> I I r <br /> J 1N ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> -, -+---r- -I-- \ ❑Elevator ❑ <br /> w E T CASING MATERIALv HOLE DIAM. <br /> Drive Shoe? ❑Yes [ No <br /> ▪- -T- - ❑Steel ❑Threaded ❑Welded <br /> i i i '/2 Mile <br /> ❑Plastic ❑ <br /> i . <br /> CASING <br /> ' S ' Diameter Weight Specifications <br /> 1 Mile I in.To ft. lbs./ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To' ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> ;; i l l Tarr Truheck <br /> Property owner's mailing address if different than well location address indicated above. -SCREEN 'a S OPEN HOLE <br /> Make .oh n S o n From ft. To ft. <br /> Type Sta.inIcP Diam. 7" <br /> Slot/Gauze 4.15 Length T <br /> Set between 145 ft.and ft. FITTINGS 3' lead <br /> STATIC WATER LEVEL 77. <br /> ft.'LJ Below ❑Above land surface <br /> Date.measured 11/2/2 2 Dry hole ❑ Yes ❑`Ttlo <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 1`t 0 ft.after hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,,, <br /> ▪Pitess/adapter manufacturer Model <br /> ❑Casing protection ❑12 in.above grade <br /> ❑Atgrade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material ' From 1 4 5 To ft. ❑Yds. ❑Bags <br /> '. 50 <br /> Material . .. From To ft. ❑Yds. NI Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing teal From To Bags One bag=94 lbs,cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Sand/Gravel S Well is •--1`. _. feet direction from C- type <br /> Well disinfected upon completion? Yes ❑No <br /> &Jaridy Clay Brown yf 42 51 PUMP <br /> ❑Not insta ilea Date installed 1 2-/6 <br /> Clay/Sand Gray 51 77 Manufacturer's name r'ha f e r <br /> G TI f. <br /> Model Nunher_ HP t . Volts <br /> Clay <br /> Length of drop pipe 1 0 r ft. Capacity g.p.m. <br /> -x 7 Q 146 6 155 Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ — <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes ❑No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes ❑No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. <br /> Use a second street,If needed. The information contained in this report is true to the best of my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Business Name Lic.or Reg.No. <br /> /,1-'Z./4-1.4: • <br /> Ce tided epresentative Signature Certified Rep.No. Date <br /> R, Rob Stodola <br /> LOCAL COPY 1 4 t ` 1 F [# <br /> Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />