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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name <br /> 'WELL AND BORING CONSTRUCTIONTRECORD f 4 <br /> ��; <br /> yl P5v\a p 10 Minnesota Statutes,chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction(sm.- .lg.) WELL/BORING DEPTH(completed) DATE WORK C MPLETED <br /> Orono t t1 23 Io E 5. 4 N } 125 ii. I is D,-j - <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 /> ti <br /> 1 2,i1 La k V ICI w Ave. O, Dino 55 3C I DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. ti A-or11 I . From ft.To ft. <br /> Showing property lines, <br /> roads,buildings,and direction. USE <br /> N -sfil Domestic ❑Monitoring ❑Heating/Cooling <br /> I I I I 17\1 <br /> _J_ L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> �` <br /> ❑Community PWS ❑Dewatering ElRemedial <br /> _ ___ ___F_—I— ❑Elevator ❑ <br /> w ET <br /> CASING MATERIAL Drive Shoe? ❑Yes X No HOLE DIAM. '' j <br /> ❑Steel ❑Threaded ❑Welded . 'I <br /> 'h Mile 7 Plastic ❑ -.j <br /> CASING <br /> J s _ _ _ - Diam�e{ter - - —Weight Specifications 1 <br /> I 1 Mile ❑ � -' r{ in.To '15 tt. lbs./ft. `/ in.To 50 ft. <br />_,; PRO <br /> PPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. ;I Z in.To' ft. <br /> Je-nnt cc)," JV 3 in.To ft. lbs./ft. in.To ft. i <br /> Property owners mailing address if different than well location address indicated above. <br /> SCREEN 1f'S OPEN HOLE I <br /> Make .)C'\V\CO f-1 From ft. To ft. <br /> SO. e, Type min I yl Ve S5 Diam. 2 1 <br /> Slot/Gauze Length 1 <br /> Set between I I b. ft.and 12 5 ft. FITTINGS PG 6 <br /> STATIC WATER LEVEL <br /> ft. [F1 Below ❑Above land surface ! <br /> t i <br /> Date measured ' 'Z` ' Dry hole ❑Yes ❑No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after �' hrs.pumping 5o q.p.m. 1 <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION J� <br /> 1 Pitless/adapter manufacturer 1"t i F'n I ( Model <br /> ❑Casing protection X12 in.above grade I <br /> ❑At-grade ❑Well House ❑Hand Pump J <br />• <br /> GROUT,INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) J <br /> 1 1 <br /> Materia..,[U� 11I'1t�S From 1 I S To 50 ft. 7 ❑Yds. ❑Bags <br /> Material Jf t1 I to From 1%7 To O. ft. 3 ❑Yds. ©Bags <br /> HARDNESS OF Material From To ft. ElYds. ❑Bags I <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 <br /> CSSOURCEOFCONTAMINATION �I t j' et1.')e tr <br /> L`tf <br /> a- {it kitl \ `i J 6F\ r I,ry 11( ,:.d'- 0 )Li Well is feet direction from Cii If le de CI type <br /> // i } /yu� Well disinfected upon completion? 'Q Yes ❑No II <br /> \_ 6.t t (HI"({-`1 Gx�1 i ! PUMP (� <br /> y, ) ❑Not installed Date installed �' 1 <br /> C ELL ( 1.\ L...-)Y cc) t Sa -ILt 1 1- Manufacturer's name 51 V a k <br /> l 1'1 C, \. Model Number 1.- HP Volts 1 <br /> Length of drop pipe f� ft. Capacity g.p.m <br /> xy.'": ' Type:Xc Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> A <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes No 1 <br /> VARIANCE 'I <br /> Was a variance granted from the MDH for this well? ❑Yes %No TN# 1 <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. i <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. ` Iy <br /> 11\ StoAC\(., \I\JQk\ V1,I\Inc) 1‘411 <br /> Licensee Business Name Lic.or Reg.No. <br /> I <br />.. .v.:-.5 - I 1 15\ LI <br /> Z. '4-..),, . ,...„,- - <br /> ertified Representative Signature Certified Rep.No. Date -, <br /> i� d t`''�1 I 1 <br /> LOCAL COPY 8 7 3 5 4 9 d <br /> Name of Driller <br /> ID 852603 - HE-01205-18(Rev.3/19) <br /> ,41 <br />