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�_ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 612 7 0 5 - <br /> ��ij��, �a Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> ��@ II� 23 33 '�'��. SFti f��1�. 15� 12�28 98 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 170 CZ E3�F3.�. CTr..fx ❑ CableTool ❑ Driven ❑ Dug <br /> k Ao3d ❑ Auger Cl�Rotary _ O 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 O <br /> N <br /> � � � � h$?2�'t3���.t� FROM n.co n. <br /> I I I I <br /> ��� USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i ^�K.�,„ �Domestic ❑ Communit PWS <br /> `�„ Y ❑ Industry/Commercial <br /> � -� i i � ❑ Irrigation ❑ NoncommunityPWS ❑ Remedial <br /> w e ❑ Test Well <br /> � � i i (.{ ❑ Dewatering ❑ <br /> i i i i ��ZM_a � CASING Drive Shoe? ❑ Yes o HOLE DIAM. <br /> i i _i_ _i_ ��// ❑ Steel ❑ Threaded ❑ Welded <br /> -i -i- i i <br /> 1 � L�Plastic � i1..�11� _ <br /> �1 Mile� � <br /> CASIN DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME `" � in.ro ��� ft. Ibs./R. �� in.to4�5+�ft <br /> �i�.l'd�X xaDlG� in.to tt. IbsJft. ��; in.to 1-�'-ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. _Ibs./ft. in.to ft. <br /> 7�V E89� Lt�k6 StrE@t � � � �� �� SCREEN OPEN HOLE <br /> Make �<?�CL� from ft.to ft. � <br /> 11Pe�T:i.i:1L'8! �;iv 5539� �;I.��S �(, � ��',' ` Type_ �1G Diam. <br /> .T �► 1� �ength �� <br /> SIoUGauze <br /> .�, Setbetween 1G7�-15t�ia�d I5�^ ft. FITTINGS: K--parker <br /> �;,��t v r-��;r�r���,�d: <br /> STATIC WATER IEVEL <br /> WELL OWNER'S NAME �� ft. �below ❑ above land surtace Date measured '�"��f <br /> PUMPING LEVEL(below land aurface) n <br /> Well owner's mailing address if different than property ownePs address indicated above. ft. after �/� hrs.pumping �� g.p.m. <br /> WELL HEAD COMPLETION <br /> �Pitlessadaptermanufacturer �38P3 Model �1�� <br /> ❑ Casing Protection _❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �'es ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material P�eat cement �entonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL from � to �F�J ft. 3 ❑ yds. � bags <br /> from to ft. ❑ yds. ❑ bags <br /> �;f.'i,7 Ytx1�.G'iQ � 3� from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION ���� <br /> ���z3,,' Gray 3{� Ets feet direction _type <br /> - Well disinfected upon completion? C9Xes ❑ No <br /> /�. <br /> Gr�vel �iXP.(� Fi� ��} PUMP <br /> ❑ Not installed Date installed !!�!V� <br /> Gravel/CJ.�.y ���q �� ��� Manufacturer'sname ����fi <br /> Model number HP � Volts <br /> C1a1r t�r�.;; 145 I3f? 12f1 15 <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type: C�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ '' <br /> r..•��-;�?./Ss;.-.z,a ��i.x��cx' I30 152 <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 <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 /> St�verz^ '���I.l t.-iri� & En��. Sera�ir�s �r36F�54 <br /> Licensee Business Name Lic.or Reg.No. <br /> _ _ .___ 21�0/�� <br /> Authorized Representative Signature ����- Date <br /> Ratnc�=� J�h*�son <br /> ,�+ r Name ol Dnller ��� Date <br /> LOCAL COPY 'LJ �2 7� �O HE-01205-06(Rev.9/97) <br />