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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 �- 8Minnesota Statutes,chapter 1031 6 6 - <br /> Township Name Township No. Range No. Section No. Fraction(sm. - +lg.) I WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> 1 1 7 1' '/a /a ft. 'I 2/31 .(1'7 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude- E Cable Tool E.Driven 7 Dual Rotary <br /> ❑Auger ❑Rotary [ Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑',Other <br /> •sq�? _ r 3],�,. ' ; rZ CO P n DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. T'*-r,t-r-.;_,-: f"r:, From ft.To ft. 1 <br /> Showing property lines, <br /> N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling <br /> ._fl -- ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ��� �,.� 9:j I;.1. } <br /> ▪ � � � e: � LI/ <br /> � ..,.. ❑Community PW5 ❑Dewatering ❑Remedial <br /> ---+--- ❑Elevator ❑ <br /> w ECASING MATERIAL HOLE DIAM. <br /> T <br /> Drive Shoe. ❑Yes ❑No <br /> ▪ --T---r ❑Steel ❑Threaded ❑Welded <br /> 1 I <br /> /z Mile I ❑Plastic ❑ <br /> ICASING <br /> s 1 Diameter Weight Specifications <br /> j 1 Mile j in.To ft. lbs./ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. n.To ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> e8e1 C O sc <br /> fi SCREEN `�' OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> Make Jo I S O I_"? From ft. To ft. <br /> 650 Bunker Lake Blvd NW 7 <br /> Anoka, MN Slot/Gauze •1 2 Length I <br /> Set between )il ft.and 1 6 2 ft- FITTINGS II <br /> STATIC WATER LEVEL/ . / ? ft. ❑Below ❑Above land surface <br /> Date measured 1 1/ 1 / 2 2 _ Dry hole ❑ Yes ❑No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 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 /> ❑Pitless/adapter manufacturer Model <br /> ❑Casing protection ❑12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material .711#' t 1 From 1 54. To ft. ❑Yds. ❑Bags <br /> Material 0 From 5 C To ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ElYds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement <br /> Driven casing seal From To Bags = <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Clay Well is _feet direction from type <br /> Well disinfected upon completion? ❑Yes ❑No <br /> -r PUMP <br /> T <br /> /3 a n <br /> ❑Not installed Date installed . <br /> 7'Cave 1!-a#-- 7 Manufacturer's name •^-e C <br /> 1 <br /> Model Number HP _- • • Volts <br /> rinry <br /> '' .-Ca °? 9'f Length of drop pipe ft. Capacity g.p.m. <br /> y ;^....., off L 1 1 Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> land ^d, Does property have any not in use and not sealed well(s)? ❑Yes 1R.No <br /> VARIANCE <br /> l ''rav 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 /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> °_on c 3-r' nl a 'Tra1-.?, nri 1 1 i n ('r^ti <br /> Licensee Business Name Lic.or Reg.No. <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY P <br /> Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />