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��C�6�'�'�' <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> CounryName � � � 5 'g�/ELL AND BORING RECORD 615 212 � <br /> �<311Ii@pgXt Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range;N9.� ' S�ct�on�N�..�,�F,r�a n WELL DEPTH(completed) Date Work Completed <br /> OlOAO �.�� �� �3 PI ,��1��. '�J�v. 1�'J� n 1IJ24/9�3 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 13� Crysta� Cir@@�{ GrC�3�0 55� ❑ 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 buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES Q�O <br /> " .._._._�_�_ �L1�CK G�.� <br /> i i i i FROM ft.to ft. <br /> -i- -i- -i- -i- ,_..-=�"� <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i � �� /`���� �Domestic ❑ Communit PWS <br /> -�- -�- -�- -�- - -- ❑ Irrigation Y ❑ Industry/Commercial :� <br /> i i i i -���� ❑ Noncommunity PWS ❑ Remedial <br /> w E T �� ❑ Test Well <br /> � i i i ,} ❑ Dewatering ❑ <br /> -r -�- -r- -r � .., <br /> i i i i '/zIM.1e � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i i _i_ _i_ � ' � ❑ Steel ❑ Threaded ❑ Welded <br /> � _�- � � € �Plastic ❑ <br /> S 1�.._J <br /> �-1 Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to �.'�8 ft. �U� Ibs./ft. 8 5�j_ <br /> in.to <br /> �i,�r�1C� (?a���tl�� in.to ft. Ibs./ft. _in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. _Ibs./ft. in.ro ft. . <br /> G`/E� J fland HOS��S SCREEN OPEN HOLE <br /> 15U Soath Nraadxay l�ve. Make a����.'� from tt.to ft. <br /> �a ���i�f � .JJ37�. TYPe ���t. Diam. f�M <br /> Y SIoUGauze �� Length 10� <br /> Set belween ��� ft.and�_ft. FITTINGS: <br /> STATIC WATER LEVEL , <br /> WELL OWNER'S NAME ,�(�, ft. q�pelow ❑ 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. Z�� ft. aRer 3 hrs.pumping �{� g.p.m. <br /> WELL HEAD COMPLETION .t C <br /> l�Pitless adapter manufacturer ��i�i@��*.8lr Model S"�J"'4 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Wellgrouted? ❑]�s ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ❑](igh So�ids Bentonite <br /> MATERIAL <br /> from_��to�ft. _� ❑ yds. C�bags <br /> � �O from to ft. ❑ yds. ❑ bags <br /> Cl.ay �ri��n ��� from to ft. ❑ yds. ❑ bags <br /> ,ya C� NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ciay blue �ea. � ,� ficx�r ar�,t <br /> �2 feet ��g�. direction <br /> sasc� S� �ravel mix <br /> med•� Well disinfected upon completion? C�'es ❑ No . <br /> � s 52 87 PUMP <br /> ����� �Y�V ���e ���• �� 1 a� �lot instalied Date installed <br /> •f y <br /> ; 1 Manufacturer'sname `l, yc., t� ��t-� <br /> ���� � �r�ve� �,q� ��d:� Model number HP � Volts �`�U <br /> ; �Dur$G �.�7 �.�✓ Length of drop pipe � L�t/ 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 O�lo . <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? C7 Yes ❑�b <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 /> The information contained in this report is true to the best of my knowledge. - <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> R}sS �tell Drillin� �72��i <br /> � Licensee Business Name Lic.or Reg.No. <br /> � J <br /> .d-1;-- ,.- ' /'� i� �' /!/L/ '� � <br /> Authorized Representative Signature Dat <br /> Bs�bett �. �todol�►, Jr. i/14/99 <br /> Name of Driller Date <br /> LOCAL COPY 615 21� <br /> HE-01205-06(Rev.9/97) <br />