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[ K � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 4 9 2 3 9 <br /> Henne�i n Minnesota Statutes Chapter 103! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> OtOnO 118 Z �� �� '�• ' - - <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ��� ❑ Cable Tool ❑ Driven CI Dug <br /> 175 Cr S a • ❑ Auger �1 Rotary ❑ Jened <br /> Show exact location ot well in section grid with"X". 5�3 S b SkelShowaPq�dipert lainleg, � <br /> , roads;�nd bui mQs. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �q�JO <br /> N <br /> , , , , QLi�Ck— @1 FROM_ n.io n. <br /> -,- -;- -;- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i � � . �7 Domestic ❑ Communit PWS <br /> -�- -a- -�- -�- i `fJ Irrigation Y ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> yy E T � - ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> i i i i I <br /> -r -�- -r- -r . <br /> � i i i ��2M e � "�,,. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> i i i � ❑ Steel ❑ Threaded ❑ Welded <br /> -� - �- -� - -� 1 ;��. �] Plastic Xl �llle <br /> S �' <br /> �-1 Mile--i <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 1� in.�o_��.�ft. __�� Ibs./ft. ���(�_� <br /> RV�r H�Q��$ — in.to fl. -_--- --Ibs./ft. �in.toi�_'tlft. <br /> Property owner's mailing address if different than well location address indicated above. in.to_____fl. ________ Ibs./ft. in.to R � <br /> SCREEN OPEN HOLE <br /> Make_ _T���_.__ from ft.lo__, ft. <br /> Type_�`�= Diam. � <br /> SIoUGauze _ Length A t _____.__ <br /> Set between 1 '7�_'�R.and��__ft. FITTINGS: 7�.�7n w n..�.+ 1 ade� <br /> STATIC WATER LEVEL K� cke� <br /> WELL OWNER'S NAME _�_� ft.�below ❑ above land surface Date measured_n��_a�n� <br /> PUMPING LEVEL(below land surface) <br />� Well owner's mailing address if different than property owner's address indicated above. _}'��ft. aRer__,7 _ hrs.pumping� g.p.m. - <br /> i <br /> WELL HEAD COMPLETION <br /> �1 Pitless adapter manufacturer r���`�� Model <br /> ❑ Casing Protection__ _ __.__._ � 12 in.above grade <br /> ❑ At-grede(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? LXYes ❑ No <br /> HARDNESS OF Grout Material C] Neat cement ❑ Bentonite ❑ Concrete High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from�_to _�__ft. _ _ _ ❑ yds.,�bags <br /> from_ 7A tot �7�.___tt. �����$S yds. ❑ bags <br /> �v iT <br /> � � from to R. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> __,_g_�___,feet ___�______direction �ranr�type <br /> � � <br /> Well disinfected upon completion? � Yes ❑ No <br /> PUMP <br /> ❑ Notinstalled Dateinstalled . +����+�oo _ <br /> Manufacturer's name __ ._�''$���__ . . _ _ _ _._ -- <br /> Model number _ _ _ __ _.__ HP _�*�_ Volts__�_�____ <br /> Lengthofdroppipe ____.�,_2_�_ ._ ___ tt. Capacity _g.p.m. <br /> Type: T�Submersible I.-1 LS.Turbine ❑ Redprocating ❑ Jet Cl _____ <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 tor ihis well? ❑ Yes �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 /> The information contained in this repoR is irue to the best of my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> DOAi STODOLA idELL DRILLYNG C0. , INC. <br /> Licensee Business Name-� . Lic.or Reg.No. <br /> ----�- �„ 2 7 i 7 2 <br /> /- - _:,� <br /> u onze� ta ve�i nature �Date <br /> Duane Mathews 8-10-00 <br /> 6 4 9 2 3 9 Name ol Driller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />