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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 2 7 2 3 6 <br /> Henne in Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH�completed) Date Work Completed - <br /> ft. <br /> Orotzo 118 23 33 ��. ,, ,. �61 7/2�/99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 60 Cr s�t1 Creek Rogd ❑ 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 buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES�NO <br /> N <br /> i i i i � Wr�t$r FROM ft.to fl. <br /> -i -i- -i- -�- ,..,,���- <br /> � � ���. USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � � r� Domestic ❑ Communit PWS <br /> —�— —J— —�— —�— e��! F-.' �-t�' �Irrigation Y ❑ Industry/Commercial <br /> i i i i ;q,...� ❑ Noncommunity PWS ❑ Remedial <br /> y� E T b*� S, � ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> -i- -�- -r- -r I \�,,r \ . \�.,...-. <br /> i i i i / , �' �' �� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> - - y2M,_L� � l�l�- <br /> i_ _ i_ _i _ _i ❑ Steel ❑ Threaded ❑ Welded <br /> ' ' ' ' �P�astic �.. glue <br /> s <br /> �1 Mile� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to 1�6 ft. Ibs./ft. ��Y�n.to i�ft. <br /> Pillar �01�C2i in.to ft. Ibs./ft. � <br /> �fy���.co�n. <br /> Property owner's mailing address if ditferent than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> 7�iO F.r19C LB�SC S�re�'L SCREEN OPEN HOLE <br /> �ilayzata, :�? 55391 Make J��rcn r�om n.co a. <br /> Type �!� Diam. <br /> SIoVGauze Lengih �f <br /> set between n.and 1 b� n. F�rrwGs: �—p$ck <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME �-Q� ft.�•below ❑ above land suAace Date measured Y �"�"r C <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 �Q g.p.m. <br /> WELL HEAD COMPLETION t.�� <br /> ❑ Pitlessadaptermanufacturer�gx+t$ Model '¢ <br /> � ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> a; ' GROUTING INFORMATION <br />� Well grouted? `Q.Yes ❑ No <br /> s� GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement I$,Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL from d ro �5 tt. 3 ❑ yds. �bags <br /> from to ft. ❑ yds. ❑ bags <br /> Cl�y 'Y'`�'`1'Gw �3 3� from to ft. ❑ yds. ❑ bags <br />� NEAREST KNOWN SOURCE OF CONTAMINATION �,: ;•;i (ij rM', <br /> Ci�.c3?.' t'iL1y .�Q !� feet direction type <br /> Well disinfected upon completion? '�..Yes ❑ No <br /> CJ_:�v IGr�iV�1 �1c-�..xk GT"•r 7O 10.5 PUMP <br /> J ❑ Not installed Date installed 1 a/�/99 <br /> CI�y Grau IC�S I4t', I�q,�ry <br /> Manufacturer's name <br /> Model number HP I Volts <br /> Sand/GruvEl Mi.��� I4� �51 <br /> Length of drop pipe 14� ft. Capacity �� g.p.m. <br /> �x,aV��.�L•1c�.J kk?t� 1�2 I�T•t Type:� Submersible ❑ LS.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 � No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> S <br /> Use a second sheet,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 to the best of my knowledge. <br /> Stenens �rillin�, t4 Env. Servicrs 86654 <br /> ; .LicQnsee Business Name Lic.or Reg.No. <br /> �`'�i+�P� ;�\� ,� � 1r`, `-=`�.--�--�1.0/25/99 <br /> , <br /> Authorized Representative Signature Date <br /> �ndy 3c�hn�ert <br /> Name of Driller Date � <br /> LOCAL COPY 6 2 7 2 3 6 HE-01205-06(Rev.7/98) <br /> � <br />