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, WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD „ <br /> He n�e p i� Minnesota Statutes Chapter 1031 � � � � � � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orona 127 23 t? ,, ,,, ,, 111 � � 12-9-�38 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> I655 Nt7hriS PofTit Ro1d Orflno, M11. 5539 n CableTool ❑ Driven ❑ Dug <br /> ❑ Auger ,l�I Rotary ❑ Jetted <br />� Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buil ings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> N i,+d"d�el� <br /> i i i � FROM ft.to ft. <br /> -i -i- -i- -i- ---- -- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i � Domestic ❑ Communit PWS <br /> _i_ _�_ _�_ _i_ Y ❑ Industry/Commercial <br /> � � i i ❑ Irrigation ❑ Noncommunit PWS <br /> w E ❑ Test Well <br /> Y ❑ Remedial <br /> i i i i T ❑ Dewatering ❑ <br /> -r -7- -r- -r <br /> i i i � �/zIM1e � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ i_ _i_ _i_ � � ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> � �Plastic ❑ <br /> �—,M,�e—� .Y N/�t�- a <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to 1 d Z n. SDR—��. Ibs./n. 7/`�� 3�ft. <br /> ctoneli�n�e �.Q[ZFf�ruCt�.�Yl in.to h. ibs.in. ,n.co�_��n. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. � in.to ft. <br /> 33$? �ro�rniow �j�TQ♦ SCREEN OPENHOLE <br /> SL� LOt1�S Park, ?�SN. 5542�6 Make Jahnsen from n.�o n. <br /> TyPe a��$���e�s-S ��ee�. Diam.�w <br /> SIoVGauze t� 1 1 1 Length $� <br /> Set between Z V 2 ft.and .��_ft. FITTINGS: 3 t <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME ___ r'J S • ft.�Q below ❑ above land surface Date measured �7..Q�.g <br /> PUMPING LEVEL(below land surtace) <br /> Well owner's mailing address if different than property owner's address indicated above. g Q ft. after �� hrs.pumping �_g.p.m. <br /> WELLHEADCOMPLETION t,,,�itewater <br /> C3�Pitless adapter manufacturer Model <br /> ❑ Casing Protection � 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br />�� � Well grouted? �Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement OXBentonite ❑ Concrete Q�High Solids eenronite <br /> MATERIAL from__�__to__�Q_R. _�:r�_ ❑ yds. C�bags <br /> C 1 a y yg�Z�pp� s (}� 2 Q• from to n. ❑ yds. ❑ bags <br /> from to_ ft. ❑ yds. ❑ bags <br /> NEAR SOURCE OF CO TAMINATION �~^ <br /> Clay Grey S 20'40' �' �'/s�;�T� �r-�Ed��ic <br /> feet directio rype <br /> Sa n d 'j`a�'1 S �Q� � 1� � Well disinfected upon completion? �1 Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed ���.���� <br /> Manufacturer'snanme ��� Jacket <br /> Model number v�'����OA� HP j 1 VolOts b�O <br /> Length of drop pipe v Y ft. Capacity_ �'Q�r� g.p.m. <br /> Type:� Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �1 No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑xlo -�- <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> n�N STi}DOLA ��ELL DRILLrNG C(3. , IAiC. <br /> � � Li nsee Bu iness Name ,<� -�•� Lic.or Reg.No. - <br /> 27172 � <br /> � ��'' � - �� <br /> ..�e ":`f- .���� 6-8-9 9 <br /> � Authorized Representative Signature Date <br /> Fr�� ��i by 12-9-98 <br /> Name of Driller HE 01205-06(Rev.9/96) <br /> LOCAL COPY 5 g 7 Z � g <br />