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F . �. .. <br /> (-.. . .. . . . ,. . . . _ <br /> �. . . <br /> '1. � • + <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounryName WELL AND BORING RECORD 1 <br />, Hennepin Minnesota Statutes Chapter f037 �� �y � �. � ' <br /> Township Name Township No. Range No. Section No. Fraction WEIL DEPTH(completed) Date Work Completed � <br /> OrOnO 117 Z3 0$ ,,, ,, ,,, 120• ry 1-27-00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> � ❑ Auger O�totary_ ❑ Jetted <br />�. Show exact location of well in section grid with"X". Sketch map of well location. ❑ ' - - <br /> . Showing property lines, <br /> WLL� roads and buildings. DRILLING FIUID WELL HYDFOFRACTURED? ❑YES ❑NO <br /> N �' x j <br /> � i i i �nt�nite FROM ft.to ft. <br /> -i -i- -�- -�- <br /> � USE ❑ Monitoring ❑ Heating/Cooling <br /> � i � � �omestic ❑ Communi PWS <br /> ❑ Irrigation ry ❑ Industry/Commercial <br /> -i- -�- -�- -i ❑ Noncommunity PWS ❑ Remedial <br /> yy E T ❑ Environ.Bore Hole <br /> i � i � ❑ Dewatering ❑ <br /> i � i -r ��ZIM,ia CASING Drive Shoe? ❑ Yes �o HOLE DIAM. <br /> i i 1_ _� ❑ Steel ❑ Threaded ❑ Welded <br /> � , � � 1 �o� <br /> ��ast;� o <br /> s S <br /> �-1 Mile-� � <br /> S CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �� 4 in.to 1 1 a ft. �.�QS Ibs./ft. 8 in.to� 3�0/�ft. <br /> Bob Ff tch in.to tt. Ibs./ft. �in.to4_`Yft. <br />�� Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> 11725 54th 1l�e• �• SCREEN OPENHOLE ' <br /> Plysouth, Nn.55442 Make Jo�nson from n.�o n. <br /> Type Diam. 7 M <br /> . SIoUGauze A 1 A Length e• __ <br /> � <br /> Set between �1�_ft.and__}�_ft. FITTINGS: 9����/ <br /> STATIC WATER�EVEL <br /> WELL OWNER'S NAME '�� ft. O=elow ❑ above land surface Date measured 1 Z�27� � <br /> PUM1PING LEVEL(below land suRace) 1 <br /> Well owner's mailing address if different than property owner's address indicated above. 107 R. after Z hrs.pumping SO a 1 r g.p.m. <br /> WELL HEAD COMPLETION <br /> �itless adapter manufacturer �f t.@lfSt.@7GAodel <br /> ❑ Casing Prolection _____ X] 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> ` Well grouted? C�Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite ❑ Concrete �High Solids eentonite <br /> MATERIAL from_�_ro��tt. _��5 yds.�] bags <br /> from to___ft. ❑ yds. ❑ bags <br /> � � from ro ft. ❑ yds. ❑ bags <br /> NEARE/ST�K^NOWN SOUFCE OF CONTAMINATION�) CY f T� <br /> • • L/( , � feet ��_O C.!! �`t _direction��type <br /> Well disinfected upon completion? Q�es ❑ No <br /> � �PUMP <br /> ❑ Notinstalled Dateinstalled 3�9�00 , <br /> Manufacturer'sname Wu��� t <br /> Model number HP 1 Volts ��O <br /> Length of drop pipe 63� ft. Capacity 1� g.p.m. <br /> Type: �ubmersible G LS.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 trom the MDH for this well? ❑ Yes � No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta 7he information contained in this report is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. ZNC. <br /> Licensee Business Name � Lic.or Re .No. �� <br /> -r :� 3—Z1-00 �'� <br /> orize Representative S� ture Date � � <br /> ChuCk Moore 1-27-00 � <br /> 6 3 913 7 Name ol Driller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />