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f j <br /> WELL LOCATION MINNESOTA DEPARTIuIENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �o��tY Name WELL AND BORING RECORD 6 5 5 0 0 8 <br /> Minnesota Statutes Chapter 103/ <br /> Towns ip a Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed - <br /> n. <br /> ,. ,. 226 9—IS-00 <br /> House um er,Street Name, i y,and Zip Code o ell Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger �.Rotary ❑ Jetted ��. <br /> S ow exact locahon of we � sec ion gnd wi ". � e ch map el ocation. ❑ . � <br /> Showing property lines, � - � <br /> .� . �� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES �[l0 <br /> N '._� '.� %�_..7� �t'�..1'��-._1�.. <br /> , , , , ---_— uick— �1 FROM n.�o n. <br /> -; -,- -;- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i Domestic <br /> � ❑ Community PWS �] Indust /Commercial <br /> - _i_ _ _i_ ❑ Irrigation ry <br /> i -J i i ❑ NoncommunityPWS ❑ Remedial <br /> - w e T ;------�-�------�--� ❑ Environ.Bore Hole <br /> i i � � `` ❑ Dewatering ❑ <br /> i i r r '/ZIM1e ` �w CASING Drive Shoe? ❑ Yes �Flo HOLE DIAM. <br /> _i _i_ _i_ _i_ � o ❑ Steel ❑ Threaded ----0 Welded <br /> i- i i i <br /> �Plastic ❑ <br /> S <br /> �1 Mile-� . ,.. _..... <br /> CASING DIAMETER WEIGHT <br /> � PROPERTY OWNER'S NAME __�_in.ro_ 21 gn. sdr'�21 �bs/h _�n$o_._t� <br /> ------in.to__ ft. _ _ _ Ibs./ft. _in.to_� b <br /> rop owne i in dress if diNerent than well location address indicated above. in.to _fl. _______ _Ibs./ft. in.to ft. <br /> }�� SCREEN OPEN HOLE <br /> S$�e as a+��+0e Make �� irom ft.to ft. <br /> Type 9!t A�!12 P R fi S4�'PA� Diam. <br /> SIOVGauze_____._ /�1'1 C1 Length_ �f � I <br /> � -•��—�F--.t--- <br /> Set between _��___tt.and__�_tt. FITTINGS:_ <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME _ft.,�'below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) ` <br /> Well owner's mailing address if different than property owner's address indicated above. 21 O _ft. after___ ��J__hrs.pumping� g.p.m. <br /> WELL HEAD COMPLETION <br /> �(Pitless adapter manufacturer vh i t e�jg_�g_� Model <br /> CI Casing Protedion .�,Ff 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ,f�Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eenronite ❑ Concrete �High Solids BeMonite <br /> MATERIAL from_ to ft. [li yds.f�'bags <br /> � ��-- —�i� .. <br /> from_ to ft. Q�c�.l7 bags <br /> cIa elloW oft 0 22 f��m—�-�-- to� n n�fur� e d�f� bags F <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � sand eis ellow oft —� `ee' __-�—_ _d'��e�pti�- type <br /> Well disinfected upon completion7 �Yes ❑ No <br /> C1S rAVe� r$ f PUMP <br /> Cl Not installed Date installed��}�A�l <br /> sand �la �f Manufacturer'sname ________ .________________ ; <br /> Model number ________ HP_��_�_ Volts�Qn <br /> C1� �gQel Length of drop plpe _ __ tt. Capacity __________.__g.p.m. 4 <br /> __�-- <br /> Type:�Submersible �7 L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes fi�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? f�Yes ❑ No TN#pS� � <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,ELEVAT�ON,SOURCE OF DATA,etC. The information contained in this report is true to the best of my knowledge. <br /> Dan Stodala �tillimgCo.F_�rac-.-??t-,7 <br /> License usiness e L�c.or Reg.No. <br /> i <br /> on'rtie pr nt v ig'n - Date �� <br /> Name ol ro er �� D e <br /> LOCAL COPY 6 5 5 O O H HE-01205-07(Rev.2/99) <br />