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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 6 -� <br /> 6 Minnesota Statutes,chapter 1031 8 4 <br /> llennepirt <br /> Township Name Township No. Range No. Section No. Fraction(sm. lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <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 <br /> 525 R n a h' r s t Circle, Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. 11,ry r i From ft.To ft. <br /> Showing property lines, `` r <br /> N roads,buildings,and direction. USE Domestic [1]Monitoring ❑Heating/Cooling <br /> L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> +---�---- *` ❑Elevator <br /> w ; - E CASING MATERIALShoe? HOLE DIAM. <br /> T Drive ❑Yes ❑No <br /> T r ' ❑Steel ❑Threaded ❑Welded <br /> I <br /> -- h Mile [Plastic II-- C CASING <br /> S <br /> ' Diameter Weight Specifications <br /> H1 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 /> Levitt in.To ft. lbs./ft. in.To ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN } OPEN HOLE <br /> Make L O h f S O n From ft. To ft. <br /> 3901 Su.nryside Rd #30 + Type st— less Diem. .. s <br /> Edina, MJ T 55424 Slot/Gauze ` 4' Length <br /> Set between 1 45 ft.and 1. 5 5 ft. FITTINGS 3 f 1 e a tw <br /> STATIC WATER LEVEL ft. ❑Below ❑Above land surface <br /> Date measured 12/13! 2 2 Dry hole ❑Yes ❑No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> Swanson Homes ft.after hrs.pumping q.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION .� <br /> 1 3 60 Hamel e t Road 0 Pitless/adapter manufacturer - Model <br /> Medina, II]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 /> r <br /> Material cuttingrom 145 To ft. ❑Yds. ❑Bags <br /> Material e n t O n I tan 5 0 To ft. • <br /> ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags <br /> One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> / NEAREST KNOWN SOURCE OF CONTAMINATION <br /> r•.a1 J S EY Well is feet direction from type <br /> Well disinfected upon completion? [ Yes ❑No <br /> Tia j+'! San PUMP❑Not installed Date installed 12 r/1 4/2 2 <br /> . r O t' n Manufacturer's name `-'a e <br /> .. <br /> Model Number HP.1 1//Volts 23 0 <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type:LI 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 /> 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 'todola 7'heil flriil nv Co 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> f/ <br /> I - f. 7' 1?./1. , /22 <br /> 'Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY <br /> Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />