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� `� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 7 3 H 7 2 <br /> He nne p i n Minnesota Statutes Chapter103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt. <br /> Orono 118 23 33 �,, �,. �,. 193 2-8-02 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 165 CTystal Cceek Rd Or��Q SS3>V �] CableTool riven ❑ Dug <br /> ) �:"l Auger Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of ation. f; <br /> Showing pr p �-� lines, <br /> roads� bu dings. DRILLW FWID WELLHYDROFRACTURED7 ��YES O <br /> N � entonite <br /> � � � � FROM n.co n. <br /> ,- -;- -,-- -, <br /> � � USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i � ` �Domestic ❑ Communi PWS <br /> -i- -�_ _�_ _i_ �— f] Irrigation h' ❑ Industry/Commercial <br /> i � i i �� ❑ Noncommunity PWS ❑ Remedial <br /> yy E T 1:7 Environ.Bore Hole <br /> i � � i ❑ Dewatering ❑ <br /> � i i � �2IM e j CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> ' - '- -i- -'- y� ❑ teel ❑ Threaded ❑ Welded <br /> -� , � � 1 <br /> Plastic ❑ <br /> S 1-. <br /> �—,M�a� � <br /> �-�' CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �in.to��ft. Z.n� Ibs./ft. �in.to�Q <br /> LC�Ae�OOd DeVElO ��GTiC —_ in.to _ fl. Ibs./ft. �in.to�� <br /> Property owner's mailing address if different than well location address indicated above. —_--_._-_in.to _ fl. __Ibs./ft. in.to____ft. <br /> 2354 W l�ay��$ Blvd �D SCREEN OPENHOLE <br /> Long LBke, 121� 5�3 S Q Make $t ee 1 from ft.to fl. <br /> TYPe--- .—�}�_ Diam. �_�� <br /> SIOVGauze_ _���V �� Length <br /> Setbetween 10,1 ft.and 17�ft. FITTINGS: <br /> STATIC WApTER LEVEL .��Q`� <br /> WELL OWNER'S NAME 9 v ft.�elow CJ above land surface Date measured�—�2 <br /> PUMPING LEVEL(below land surface)j <br /> Well owner's mailing address if different than property owner's address indicated above. ���_ft. after_ i�S _hrs.pumping_�Q g.p.m. <br /> �LL HEAD COMPLETION C EWS C e C — — <br /> Pitless adapter manufacturer Model <br /> ❑ Casing Pwtedion_ ___.._�12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING WFORMATJQN <br /> Well grouted?=19 Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement p Bentonite ❑ Concrete�Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COIOR MATERIAL FROM TO �/ <br /> from_. 0 to 3O.n. Z• ❑ yds.L9 bags <br /> e1a vellov �edin� 0 3 from__���0 18� n. Q�t��_���.�� bags <br /> Y l from to _ ft ❑ yds. ❑ bags <br /> ` Q /� NEAR 1dN SOURCE OF CONTA��y/11NA/T/�q�y �"'� <br /> clay gray �Di� 3Q 7 ---� feet G.�V�-_�f directio� � ! �' type <br /> Well disinfected upon completion? �Yes ❑ No <br /> aand gray sof t 90 I� PUMP <br /> 3-�2-02 <br /> �{ S ❑ Not installed Date installed <br /> clay gray �ed3um 11� a J Manufacturer'sname Aermotor <br /> �raQel ��r SOrt lsa 1 C � Modelnumber _ *�� __ HP � Volts��Q <br /> 1 1 J <br /> Length of drop pipe __. I __ ft. Capacity g.p.m. <br /> sand bcown ��l C 155 17 Type l:: Submersible ❑ LS Turbine C7 Reciprocatmg ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes f�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? (l Yes �[�f.No TN#_ <br /> ! <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 ihis report is true to the best of my knowledge. <br /> I3on Stodels We�l Dci_1_liB�o- - Inc. 2 172 <br /> Li nsee Bu ' ss Na � �,"� ic.or Re� <br /> '� 3-22-02 <br /> , �,. ; <br /> Authorized Rep entative Signature Date <br /> Chuck Moore 2-�-02 <br /> � � � Name ol Driller Date� <br /> LOCAL COPY 6 7 3 8 7 2 <br /> HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />