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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 612 7 4 4 � <br /> ki4�'+a;��?a.�'; Minnesota Statutes Chapter f03/ <br /> � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt <br /> t�,•{7:,� 118 �3 33 �,. �,. ,, 1:34 i�/3(3iQ� <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ���' �i�'.'^.'Ci''., ?"' ❑ CableTool ❑ Driven � �,` 'Dug <br /> t <br /> ... <br /> � 7. f.i'<<�-�:� �?"il`"lt� ❑ Auger C�:Rotary:.,,, . ❑ Jetted ✓ <br /> Show exact location of well in section grid with"X". � Sketch map of well location. ❑ <br /> ! owing property lines, � <br /> ��p��. L/A_��roads and buildmgs. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> N ��t <br /> � i i i '":�t��� FROM ft.to ft. <br /> -� -i- -i- -i- <br /> USE �. ❑ Monitoring ❑ Heating/Cooling <br /> i i i i �-Domestic <br /> _i_ _�_ _� i ❑ Community PWS ❑ Industry/Commercial <br /> i i � i t ❑ Irrigation ❑ Noncommunit PWS <br /> w E �"`_^ ❑ Test Well Y ❑ Remedial <br /> i i i i ti. .�{.� ❑ Dewatering ❑ <br /> T } l/ <br /> � � _r -r y2M.ia ��C.�tE' � ` '�s��� f CASWG DriveShoe? ❑ Yes ptNo HOLEDIAM. <br /> _i i _i_ _i_ � � (E Y�Y" ❑ Steel ❑ Threaded ❑ Welded <br /> i -i- i � {� <br /> S d Plastic ❑ <br /> �-1 Mile-� � <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 1} I Z7 S� �i5 <br /> in.to ft. Ibs./ft. in.to ((�t <br /> �i��.:r l" �7��� in.to ft. Ibs./ft. �in.to��R. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R. in.to R. . <br /> !�iQ �%4.^v~ I.���Cd� .,'rS�.T�?r?t� SCREEN OPENHOLE <br /> ''••T- t 14�� ���t3� Make ����t� from_ ft.to fl. <br /> n.,:•,�,•.�' 9 . � <br /> Type Diam. <br /> SIoUGauz�� r�, Length <br /> setbetween �.�� ft.and�n. FITTINGS: � ��CIC. <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 7�f R. ❑:Ybelow ❑ above land surtace Date measured lZ 3� �}� <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 50 g.p.m, <br /> WEL�HEAD COMPLETION ���r j ta <br /> C3�Pitless adapter manufacturer �1` `' $ _ Model } <br /> ❑ Casing Protection _ d..'C12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? OFYes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement a''8entonite ❑ Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 9 <br /> from �_to 45 rc. 3 ❑ yds. o-^bags <br /> from to ft. ❑ yds. ❑ bags <br /> (;j.�' YE�.s'..UW 0 4Q from to ft. ❑ yds. O bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION A�praF. <br /> {'iTAV2�.� �i21 �I'E'y t}(} 60 feet �r _direction type <br /> Well disinfected upon completion? L1Yes ❑ Na <br /> Si3Tt{�IGI�3VC�. .�sCE3y VE'1 �G PUMP <br /> ❑ Not installed Date installed �/1�/�� <br /> Cl�ttpj S,��-.�. Grey *,�.. <br /> � �� �' Manufacturer's name '��� ' <br /> C Model number HP � Volts <br /> s�t�� Gr��' 1{�J 13� Len th of dro �"�� �-", <br /> g p pipe ft. Capacity g.p.m. <br /> Type: C�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> r <br /> ABANDONED WELLS , <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Cf3 No <br /> VARIANCE <br /> Was a variance granted From the MDH for this well? 0�les ❑�No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheeG i/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 /> S.�-N�����; �*-:�'.'�.��� & �:��r. Sexv�.6,F>> �6654 <br /> . . � Licensee Business Name Lic.or Reg.No. <br /> , Authorized Representative Signature Date <br /> " R<�t,:d;� J81ir.y':�n <br /> Name of Driller Date <br /> LOCAL COPY 6�2 7 4 4 HE-01205-06(Rev.9/97) <br />