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� � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName ��,�ne�,�ri WELL AND BORING RECORD 5 ��; �j �j l <br /> Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � Date Work Completed <br /> fl. <br /> ���';'�r�;� I 1 "t �;:.. 1.�� � �;_'; o �r' �_c — <br /> ��, �, �. - <br /> House Number,Street Name,City,and Zip Code o1f Well Location or Fire Number DRILLING METHOD <br /> �:��":; DE?f�Y' �Zl,ij'! �j"r41.11 (,I�L��I��r �1 2. `_.�. :rif> ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger C�SRotary O Jetted <br /> Show exact location of well in section grid wit "X;',�� �J yJ Sketch map of well location. ❑ <br /> c Showing property lines, <br /> �'Toads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> N <br /> ���� BEJ'li.�.��Il� : .. FAOM n.to h. <br /> -�- -�- -�_ -�- x �' USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i � C]xDomestic ❑ Communit PWS <br /> _i_ _�_ _�_ _i_ ❑ Irrigation y ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> W I i I 1 E� ❑ Test Well ❑ Dewatering ❑ <br /> i i i r ,/ZMie CASING Drive Shoe? ❑ Yes o HOLE DIAM. <br /> _i i � _�_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i - i- -i - i <br /> C37'Plastic ❑ <br /> s <br /> �-1 Mile� <br /> CASING DIAMETER WEIGHT <br /> i <br /> PROPERTY OWNER'S NAME � in.to � � ft. � '� Ibs./ft. �� in.io `6ft. <br /> �f,._-'t�-'I_ [-iT'.:�2i��.:"r`, �7.:tiit�3c1T���' in.to n. �bs./n. ��irf:�to�—�'�ft. ' <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN -r.1,.........�. OPEN HOLE <br /> �:.TI7TS�u\ST�- <br /> Make from ft.to ft. <br /> Type -��'t�'.' {.�. �'tC..''LZ Diam. ` <br /> SIoUGauze • } } �p�" �Length <br /> Set between � /7 � ft.and��ft. FITTINGS !.n � 5O� S+.'; � <br /> STATIC WATER LEVEL <br /> t�' t �t_.'. <br /> WELL OWNER'S NAME `_1 ft.2� below ❑ above land surface Date measured _;{i—� <br /> PUMPING LEVEL(below la�d surface) <br /> Well owner's mailing address if different than property owner's address indicated above. � i.i F ft. after ! . �� hrs.pumping c'.^ c i 1 1"�g.p.m. <br /> v�tFLL HEAD COMPLETION <br /> �x G�1�2�.�4i'�i'i:E:Z <br /> Li Pitless adapter manufacturer 'Model <br /> ❑ Casing Protection �12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? C��Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite O Concrete ❑ddigh Solids Bentonite <br /> MATERIAL � from to ft. ❑ yds. ❑ bags <br /> ��C>�3 5C�]..� �i�'r:C fC `; �. ' � � irom to_ ft. ❑ yds. ❑ bags <br /> ~ from to ft. ❑ yds. ❑ bags <br /> '� r ^ i �NEAR �0 lSOURCE OF Cpp�,MINATION <br /> ti y<'i� bZ'Ob;F'i .� _, �_ `�.,, �. -rcf � <br /> feet '---�G�✓/ )� direction'J� �� type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> c�, y Gr��y �: . _ t �: i <br /> PUMP <br /> .�'ii4(: �z2 : VFT'1. l:(-�Z(:�' -�'tt �i i'- <br /> � t �c- o❑ Not installed Date installed ��`��' <br /> Manufacturer's name ��'f.! a��aC�CE.`� <br /> i.t<1�� G7.��„'ti" �.; };: E j t��!. �odel number HP �� Volts ?'��� <br /> Length of drop pipe �� ft. Capacity 1�`� g.p.m. <br /> ;�t3,TlC�. � i.],T�r?j r9ZQy .��i �!.'!.! + � �J� tType: �T'6ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> 3 ABANDONED WELLS <br /> :'�.�:il(� �C 1 t.�(�1 F.!`1I i �'i � :r i F ��S`' tDoes property have any not in use and not sealed well(s)? ❑ Yes �o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �TJo <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 this report is true to the best of my knowledge. <br /> �2`-,Ft �.J�i�: :;�."tf'����rL`. L"v3Z"�.il� ��'1�.L1.ZlvV L.ls. � IjVC. <br /> � �9�v Licensee Business ame Lic.or Reg.No. �� ~� <br /> `�.iL� � -'� ",�� ; . _:-9� <br /> . �.,�- <br /> fi-�%�i%�'�� Authorized Representative Signature Date <br /> ..,} � <br /> �%�° C�tti�i"1ri I�Sr7c,Y� '� (.;... i_`i'i <br /> Name ol Driller Date <br /> LOCAL ��r Y 5 9 6 d � � HE-01205-06(Rev.9/96) <br /> , <br />