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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 5 7 2 7 21 <br /> H�nnep i n Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> OrOna 117 23 8 W ,SE, Sid , 2�� " 9/18/96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 3826 Cherry AV� ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �] Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> X �� Showing property lines, <br /> ��j roads and buildings. DRILLING FLUID L� <br /> N UETItOC�l I. . <br /> � � � � <br /> -,- -;- -,-- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i � �7 Domestic <br /> -�- -�- -�- -�- ❑ Irrigation ❑ Community PWS ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w i i I i E T ❑ Test Well ❑ Dewatering ❑ <br /> -i- -,- -r- -r �2IM_1e CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _i_ _L_ _i_ I ❑ Steel ❑ Threaded ❑ Welded <br /> � � � � 1 <br /> �1 Mile� <br /> X 3�] Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 ;� �0 203 n. 20Q 3�S.�h. 8� in.to�7��6�0n. <br />- Richard Hanson ;�.,o tt. ,bs.,n. <br /> �in.ttf��+ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> MakeJa CO from ft.to ft. <br /> Type Diam.__,_�_ _ <br /> SIoUGauze �f Length <br /> Setbetween � ft.and L0� ft. FITTINGS:K Packer <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 3 5 ft.� below ❑ above land surface Date measured <br /> PUMPI LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. �� ft. after 3 hrs.pumping 50+ g.p.m. <br /> Vj��FLLHEADCOMPLETION w�itewater �J�S�� <br /> �d�itless 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 /> HARDNESS OF Grout Material ❑ Neat ce �7 Bento e ❑ Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �� � 9 <br /> from to ft. ❑ yds. ❑ bags <br /> �O� 5��1 black �'{f?C�. Q � from to__ft ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> sandy Cld� hro�n �e�� NEARESTK�5NSOURCEOFCONTA�M�INATION <br /> SO�t � � feet direction�eWEr pi�ee <br /> Well disinfected upon completion? �1 Yes ❑ No a i r te$'t��C� <br /> san� �ro�n zn�d. 9 19 <br /> PUMP g/24/96 <br /> ❑ Not installed Date installed <br /> SdI1(�y clay h1U� 1� $� rNanufacturer'sname St3—R�tE <br /> Model number `S � � HP Volts�- <br /> s a n c� �r a y f i n� 8 5 2�8 Length of drop pipe ft. Capaciry 1 L g.p.m. <br /> Pressure Tank Capacity <br /> Type:x'] Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? � Yes ❑ No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes 'L7 No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> R.E.S. rr7e11 Drillin� 2'727$ <br /> OCT 4 b:�''�, Licensee Business Name Lic.or Reg.No <br /> ` ��''/�%" > %'�_��t,-��.---/;�.�-`,._,. %-''�t�/%�.. <br /> Authonzed Representative Signature Date <br /> Ftobert E. Stodola, Jr, 9/7Q/96 <br /> Name ol Driller HE 01205-05(Rev.1/95) <br /> LOCAL COPY ����� �,. <br />