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<br /> �; WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO.
<br /> �- CountyName WELL AND BORING RECORD �, � � � � 3
<br /> Minnesota Statutes, Chapter 1037
<br /> Towns ip a � � Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> �,, �� , 262 `� 10-27-04�
<br /> GP DRILLING METHOD
<br /> LOCATION: Latitude __ degrees minutes _ _ seconds
<br /> Longitude __ degrees minutes seconds '.J CableTool � �Driven �i Dug _
<br /> - ,�Auger �otary �Jetted
<br />� House Number,Street Name,City,and Zip Code of Well Location or Fire Number '
<br /> JVSS �CL� AVe� LiC�� S�J�J'f DRILLING FLUID WELL HYDROFRACTURED? ❑Yes _ o
<br /> Show exact location of well in section grid with"X". Sketch map of well location. �[�L�l�e FROM ft.TO R -
<br /> Showing property lines,
<br /> N �_` , roads and buildings USE j]Monitoring �]Heating/Cooling
<br /> �'
<br /> �� ; � � ; ��'�� �� �Domestic ��Environ.Bore Hole ❑Industry/Commercial
<br /> --'--- --'-- --`-- ---'-- , i. ,
<br /> �`�.,,�� �I Noncommunity PWS ' .Irrigation j]Remedial
<br /> �� w -'-----1------`-----�- e IDri eeShoe?n9 ;�Yes NJ �~
<br /> � `! . ,� , �Community PWS
<br /> : �� CASING i OLE DIAM.
<br /> H �
<br /> T � �
<br /> � ;___ ; ._�__ ___�_ � [�Steel ��]Threaded �i elded H
<br /> :. � � � � Mlle ._—
<br /> � � lastic -�� '��
<br /> x
<br /> � ' f � 1 CASING DIAMETER WEIGHT
<br /> S � in.to ��RF ft. L�Vl Q �ft.
<br /> Ibs./ft. in.to_
<br /> �--1 Mile—� »
<br /> ___, in.to ft Ibs./ft �in.tob�ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
<br /> �tt� �� SCREEN T�r OPEN HOLE •,
<br /> Properry owner's mailing address if different[han well location address indicated above. r'� t
<br /> ' Make FROM � ft. TO ft.
<br /> � �S SL7V1'C TYPe� +� . Diam. '�������
<br /> SIoUGauze__��1�_�� . Length �- T `'f� _
<br /> Set between ZS2 ft.and��_ft. FITTINGS����}~_,_
<br /> STATIC WATER LEVEL
<br /> ��__ ft� ��below ��`�above land surface Date measured lo-��
<br /> PUMPING LEVEL(below land surface)
<br /> WELL OWNER'S NAME/COMPANY NAME
<br /> � �_ ft.after__ �,��___hrs.pumping � g.p.m. -
<br /> WELL HEAD COMPLETION '
<br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer�r�3� •�-�^�=��•^- Model_.
<br /> �Casing Protection '�12 in.above grade r
<br /> p
<br /> `�;At-grade(Environmental Wells and Boring ONLY)
<br /> GROUTING INFORMATION,�,/ �t
<br /> Well grouted �J'��Yes �No -�,/
<br /> Grout material r J Neat cement �--�Bentonite ���Concrete,/+High Solids Bentonite
<br /> from�to. _�ft. � � . -�,yds.�ags
<br /> from�__to__���ft. �a1 ',��s� ;�bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. � - �
<br /> MATERIAL ,...i yds. �bags
<br /> _ �NEAREST'KNOWN SOURCE OF CONTAMINATION
<br /> .
<br /> �...._J��feet _ direction �__�.��- : .,:.''_x.�,_��.
<br /> �and/clay brown sfot 0 17 _ '�
<br /> . _ . . We'lr'disinfecfed upon completion Yes ❑No ��
<br /> "- C�y �Ol.L ;T 1 W PUMP ..".
<br /> , y . ,, __
<br /> , - - — -- �
<br /> ___.,
<br /> : - - --- - Not in'stalled Date installed � r✓ '" �� �,
<br /> gf� �� b� �f�t. �DI► �fAO Manufacturer's name ` J- . __t��Js'�. _ _ '
<br /> i)u LEi) .. ._._ -- ,_ __... �
<br /> - � - � �� ` � � - - � � � Model number HP_�-�_Volts %7
<br /> Q'1� b�(,� $�� 42a Zh7 Length of drop pipe ((-� ft. Capecity g.p.m.
<br /> -— ._ ---_- --
<br /> _.. .
<br /> ,�,,_,�w � � Type:� ;Submersible ❑LS.Turbine ❑Reciprocating �]Jet [�
<br /> IOO� r�l�LL�tO�I� VCO�L� SO�i LlV Z�7�AB DONED WELLS.-- ,_--- .--_.._ _. . .,.
<br /> �� � � � Does property have any not in use and not sealed well(s) ❑Yes � �o ��
<br /> VARIANCE _ , . -
<br /> - � �� � Was a variance granted from the MDH for this well? ❑Yes No TN#
<br /> � WELL CONTRACTOR CERTIFICATION ..... _ . '
<br /> s ._. . � _ .__... .
<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 /> S
<br /> Useasecondsheet,ifneeded ♦■ }��� ����h�-_ ��� �;
<br /> � REMARKS,ELEVATION,SOURCE OF DATA,etc. ` � �� � St�� ���Li ��/1.11�� W�f InC• 27I7Z ��
<br /> Licensee Business Name . Lic.or Reg.No.
<br /> � , i �..�`.. . . � -� /`.�CJ� _ .�'.
<br /> �- �" A or d- epresen ativ Sign r Date
<br /> VL!{1C:RC �[�
<br /> - LOCAL COPY �� � � p � Name of Driller
<br /> � HE-01205-08(Rev.5/02)
<br /> IC 140-0020
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