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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 7 <br /> g�,�$ i� Minnesota Statutes Chapter 103! <br /> � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt. <br /> ; �rono 118 23 33 ��. ��. �. 178 7 29 9 <br /> House Number,Street Name,Ciry,and Zip Code of Well Location or Fice Number DRILLING METHOD <br /> ❑ Cable Tool O Driven ❑ Dug <br /> 140 Gr sta.l Creek Road ❑ Auger iC] 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 /> � � � � �rTBtEZ FROM n.ro n. <br /> -� _�- '�- _�- � USE ❑ Monitorin <br /> i i i i 1�Domestic 9 ❑ Heating/Cooling <br /> ❑ Community PWS ❑ Indust /Commercial <br /> ,: i � i � ❑ Irrigation ❑ Noncommunity PWS ❑ Remed I <br /> � w I I I I E ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> ' -, i i ,/2M,�e �� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ i_ _� _ _i_ � �� ❑ Steel ❑ Threaded ❑ Welded <br /> ' ' ' ' Q �4 Plastic I;]G111@ <br /> s <br /> �1 Mile-� <br /> CASING DIAMETER WEIGHT 1 <br /> PROPERTY OWNER'S NAME 4 in.to 1�3 ft. Ibs./ft. $s in.tot�+5 n. <br /> Pi11ar �DI[I$& in.to ft. Ibs./R �in.to+7$ ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to fl. <br /> ��O EBSL La�@ S�I'�@ti SCREE OPEN HOLE <br /> Make � �� from ft.to ft. <br /> �c1 j�Z8�L3� � 55�2 Type �ri Diam. <br /> SIoUGauze $ Length 5 <br /> Set between ft.and ft. FITTINGS:� g <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 115 ft.�] below ❑ above land surface Date measured 7I�9�g9 <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 5Q g.p.m. ° <br /> WELL HEAD COMPLETION tt� <br /> �I PiTless adapter manufacturer �$s Model `F <br /> ❑ Casing Protection jtt 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? L�3 Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement � Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> trom_�_to_�__ft. _�_ ❑ yds.J�I bags <br /> from to ft. ❑ yds. ❑ bags <br /> Ci�` Ye11ow 0 30 from co n. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION t�,I�:���J �4 <br /> C1a �_,� 7� feet direction type <br /> Well disinfected upon completion? � Yes ❑ No <br /> � <br /> �rav���Sand A4ixed 4 9fl Pu"'P g��5/gg � <br /> ❑ Not installed Date installed <br /> Gravel Cl�' ti1C Q I1Q Manufacturer'sname '�'4'�4r� <br /> Model number HP 1 Volts <br /> �+�3 {Tr6.' 1� 1�4 Length of drop pipe 14Q ft. Capacity 1? g.p.m. <br /> Type: Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> Sand Gravel ��.eCP_Ci J� j � qgqNDONEDWELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Kl No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �`C7 No TN# <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 /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in tfiis report is true to the best of my knowledge. <br /> Stevena Dr��iitx� & E�Qir+��nt�l Services $655 ` <br /> LigPasee Business Name Lic.or Reg.No. <br /> ' ,�`�� ' � ..i��'.+._�,�.�i_._.. <br /> ' . , 7I29/99 <br /> Authorized Representative Signature Date <br /> i�a;�d� Johasc+n 7/29/99 <br /> Name ol Driller Date <br /> - LOCAL COPY 6�7 2 3 7 HE-01205-06(Rev.7/98) <br />