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: . �. .�, . . � , Y� .,._.r ; - , <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 615 2 0 6 <br /> H C:i]l16 jJ 1�2 Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> or€�nc� 117 23 � W SE t�E I11 n y j25/��3 <br /> ��. ��. ��. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> �8s� (.+r.G��3��if.,,�� 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 /> Showing property lines, <br /> roads and ilding . DRILLING FLUID WELL HYDROFAACTURED? ❑YES C�10 <br /> " �� wat�X <br /> i i � i FROM ft.to ft. <br /> -i i i i <br /> USE ❑ Monitoring ❑ Heating/Cooling � <br /> i i i i ^�C � �[Domestic <br /> —I— —J_ _�_ _I_ L ❑ Irrigation � Community PWS ❑ Industry/Commercial <br /> I I I 1 �7 ❑ Noncommunity PWS ❑ Remedial <br /> w e� ❑ Test well <br /> i � i i ❑ Dewatering ❑ <br /> i , r -r '/zM_ie � � CASWG Drive Shoe? ❑ Yes No HOLE DIAM. <br /> _i_ _ i_ _i_ _i_ � .�` U ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> i �Plastic ❑ <br /> S ` - <br /> �1 Mile-� y <br /> � CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.ro lflb n. 2dV Ibs./ft. �_in.to_��t. <br /> i'��Z�3�a .��rt3C33Z _in.to ft. Ibs./ft. _�in.to.�j,_J�. <br /> Property owner's mailing address if different than well location address indicated above. in.to R. Ibs./ft. in,to fl. <br /> SCREEN OPEN HOLE <br /> Make J$'��'0 from ft.to ft. <br /> Type pV�r Diam. � <br /> SIoUGauze [�9 2 t Length <br /> Set between �.V 6 ft.and +I 1 ft. FITTINGS: <br /> STATIC WATER LEVEL , <br /> WELL OWNER'S NAME _ �� ft. �elow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) 9 <br /> Well owner's mailing address if diKerent than property owner's address indicated above. �� ft. after J hrs.pumping 40 g.p.m. <br /> WELL HEAD COMPLETION <br /> C�Pitlessadaptermanufacturer �t�i���'�ter Model ����� <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement C�eentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATEFiIAL from �0 to 7 n. 3 ❑ yds. OXbags <br /> from to ft. ❑ yds. ❑ bags <br /> cl,$ �13�A ln��• from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> t:j,di/ �}l.U� ��4'C�• � �� teet �`+��t direction "�"���r ��t�e` ' <br /> Well disinfected upon completion? O�es ❑ No .. <br /> �anc� b yr�vel mix m��•/ 7 11 PUMP <br /> ❑ Not installed Date installed 9/�4/9€� <br /> Manufacturer'sname 5��a'�x,C� <br /> Model number HP 1 �olts <br /> Length of drop pipe 8� ft. Capacity �.� 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 �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes Q[No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheeG il 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 ro the best of my knowledge. <br /> 8$S Well Drlllln�7 27276 <br /> (� � Licena�e Business Name Lic.or Reg.No. <br /> ' � �7�>`` <br /> � � � 9 <br /> _ . �_ <br /> Authorized Representative Sig ture ate <br /> , _ 8�ber� �. S�s�dolar Jr. �/2�/98 <br /> �iii�i <br /> �� Name of Driller HE 01205-06(Rev.9/97) <br /> LOCAL COPY �15 2 0 6 <br />