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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 615 5 71 <br /> Aenne Minnesota Statutes Chapter 703! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> R. <br /> � �� L7 '/� '/. '/� <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool O Driven ❑ Dug <br /> ❑ Auger �otary ❑ Jetted <br /> Show exact location of well in section grid with"X". C t O G L Sketch map of well location. � i <br /> �J�J� Showing property lines, <br /> roads and bu' ings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑�O <br /> - N - r�EL�- '� <br /> , , , , FROM n.to n. <br /> � -�- -�- -� USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i <br /> � �Domestic ❑ Community PWS ❑ Indust /Commercial <br /> � i i v Irrigation ❑ Noncommunity PWS ❑ Reme al <br /> yy E Q ❑ Test Well <br /> � � � � ❑ Dewatering ❑ <br /> i i i � '/2M.e �� CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> _i _i_ _i_ _i_ I . ��'�\ _ �� �teel ❑ Threaded ❑ Welded <br /> i i i i � _",,,►r.�.�...r. <br /> � lastic ❑ <br /> F-,n�ie-� � <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME k in.ro 2��n. �'g Ibs./n. g in.to ny. �� <br /> in.to_ ft. Ibs./ft. �in.to__f!7� <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> �4�'�iS ir�IIWOOd �LC SCREEN OPENHOLE <br /> �den Prgirie, M� 5S3�6 Make Johnson from ftto h. <br /> ype��-�xE��e$o_vzn�cc�Diam. '3p <br /> SIoUGauze__� ____Length <br /> Set behveen � ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME _��___ ft. elow ❑ above land surface Date measured ���=�Q� <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ��� ft. after � hrs.pumping 3..Q_g.p.m. <br /> WELL HEAD COMPLETION whi t e�s t er <br /> �Pitless adapter manufacturer Model _ <br /> Casing Protection �12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite <br /> MATERIAI ) <br /> from�to�(L ft. _�_ ❑ yds.�,bags <br /> P� C �f from�_to�_�_�ft. n��_��$_� ❑ yds. ❑ bags <br /> �+�gy y�11aw s�it 0 G� from to ft. ❑ yds. ❑ bags <br /> NEARE �QVOWN SOURCE OF CO TAMINATION � <br /> �i.��iy �C$}I $O�t �5 gQ teet �L��l direction ��'/�1�iype <br /> Well disinfected upon completion? I�'es ❑ No <br /> /� <br /> Clayloravel calore� me�lium 9� 13fl PUMP <br /> ❑ Notinstalled Dateinstalled 1�`��JU <br /> e�ay �t�6'1F1 SOtt Z�Q ��Q Manufacturer'sname ��� Jacket <br /> Model number l riflf'.NC1����t��y� votts '9ll�A/� <br /> sarid cray sofr lso 17� <br /> Length of drop pipe 1 2� ft. Capacity g.p.m. <br /> Type: �ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �lo <br /> VARIANCE <br /> Was a variance granted from Ihe MDH for this well? ❑ Yes o <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and i�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 /> Uon ��n�iol.a �Tell Dril�in�% C�. ���-.--?.7172 <br /> Lic ee Business Na e � ,�r Reg.N� <br /> / � i <br /> Kr I —� 1��C7�7� <br /> � u hori' d epresentative Signature `�� Date <br /> Chuck 1�ioore 9-3-gg <br /> Name of Driller HE 01205-06(Rev.9/97) <br /> LOCAL COPY � �, �� ( �, <br />