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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. <br /> CounryName WELL AND BORING RECORD 6 2 3 5 8 3 <br /> Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> fl. <br /> 4< 4� /. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 47t�Q Creekwooc� Trl, arono 5369 ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �otary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �QO <br /> N <br /> , , , , �¢'L1r bentonite FROM_ n.to n. <br /> ,- -,- -,-- -, <br /> M USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i A �omestic ❑ Communit PWS <br /> _i_ _�_ _i_ _i_ ❑ Irrigation Y ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w E� ❑ Environ.Bore Hole <br /> i i i i ❑ Dewatering ❑ <br /> i -, i -r +/zM1e CASING Drive Shoe? ❑ Yes �lo HOLE DIAM. <br /> _i _i_ _i_ _i_ � O Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> �lastic ❑ <br /> S <br /> �-1 Mile-� �:. <br /> CASIfNG DIAMETER WEIGHT k <br /> PROPERTY OWNER'S NAME /` ( ��j�� ��j �t in.to �-Q� ft. ��g Ibs./ft. 8 ��.to , Q <br /> RPC Ho�te� C.r�G��"'� in.to ft. Ibs./f[. �in.to�ty 6 > <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs.ttt. in.to ft. <br /> 64�5 REgency Lane SCREEN + OPENHOLE <br /> S�}en Prair3e, l'iP1 �5�•i�3 Make_ �f���`��— from ft.to ft. <br /> Type $ta n �Ss steel Diam. <br /> Slot/Gauze �(�1� Length 4� ♦ �i f <br /> Setbetween ��_ft.andT1� ft. FITTINGS:�„$'!�1_�_��k <br /> STAT{L'*N/ATERLEVEL ���� �� � <br /> WELL OWNER'S NAME �� ft.�elow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owners mailing address if difterent than property owner's address indicated above. ��,f,� ft. after ? hrs.pumping_��g.p.m. <br /> WELL HEAD COMPLETION <br /> p�itless adapter manufacturer �hi t ec�a t er Model <br /> ❑ Casing Protection_ J5C12 in.above grade <br /> - ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING�NFORMA—T`ION <br /> Well grouted? le'�res ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ,�'Fiigh Solids Bentonite <br /> _ MATERIAL from__�_ro_�_ft. �_T_5❑ yds.�bags <br /> 1 from�to 1 A Q ft. ��❑ yds. ❑ bags � <br /> C+�y �Z��p Q�t Q �5 irom to =�°r ft. ❑ yds. ❑ bags 4; <br /> NEAR KNOWN SOURCE OF CON I TION L <br /> Ciay -ray �1� ys g� feet ��—��! direction��"` �� �fype <br /> Well disinfected upon completion? C�Yes ❑ No <br /> Claqlrocks ra�n ard 65 95 PUMP <br /> ❑ Notinstalled Dateinstalled 3"`3�77 <br /> �'�8{T���►S'8flt� olared �dium 9� �.iF1 Manufacturer'sname ��C�. �8.'L'�CQt <br /> Model number I S�ensl-CNSIICF 1.S �o„S 234 <br /> Length of drop pipe Qli�� ft. Capaciry _�� g.p.m. <br /> Type: �ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> t <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �Ao <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ,�RIo TN# <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 /> en us�ness N .o g.IVS. • j• � <br /> `� �� � J' <br /> ��:. �.� _1£i- <br /> Authorized RepreseAtative Signature Date <br /> Chuck I�aore 1-21-99 <br /> . Name ol Driller , Date <br /> LOCAL COPY 6��5 8 3 HE-01205-06(Rev.7/98) <br />� <br />