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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIc7UEWELL NO. <br /> County Name WELL AND BORING RECORD <br /> Minnesota Statutes,Chapter 1037 �� �� � � . <br /> Towns ip ame Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> �� ,� ,� <br /> GPS DRILLING METHOD � <br /> LOCATION: �Latitude degrees minutes seconds ^ <br /> Longitude degrees minutes seconds ❑Cable Tool 'i_;Driven I_'�Dug <br /> ❑Auger '�Faotary �"Jetted <br /> House Number,Slreet Name,City,and Zip Code of Well Location or Fire Number � 7� <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes 14'No <br /> J-� <br /> Show exact location of w in section grid wit 'X".� Sketch map of well location. FROM ft.TO ft. <br /> Showing property lines, <br /> N �� roads and buildings USE � <br /> , -, � [,Monitoring ❑Heating/Cooling <br /> I � � I I `� omestic ❑Erniron.Bore Hole ❑Industry/Commercial <br /> i Noncommunity PWS �]Irrigation ]Remedial <br /> ; ; ' ' � ❑Communiry PWS ]Dewatering <br /> � , � <br /> --'-----'------`-----6— ....,-yst .a <br /> ; ; ; ; =1. ' ASING Drive Shoe7 ;�Yes ��No OLE DIAM. <br /> W , . , , ET <br /> __,_____;___ __�___;__ -� �, ❑Steel r,Threaded �]Welded <br /> '/nniie +�Y`- {.-.----� Plastic � - _ <br /> � � � � • '': <br /> ' � � � -� 1 '� CASING DIAMETER WEIGHT �` <br /> S '* in.to ��s+ ft. �+�1+� Ibs./ft � in.to �it. <br />� �1 Mile� � �,� -� �('�\ <br /> in.to ft Ibs./tt. �in.to�ti^+tt. <br /> PP,OPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> �+� �"'s`++���' SCREEN t OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make �iL7� FROM R TO ft. <br /> TYPe ��Ai�l�i'�'$ ��� Diam. _ <br /> � � S� SIoUGauze A1 A Length �!�T_�w� <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER L �� <br /> 12G ft. elow �,above land surtace Date measured �"'� <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME y�6 q - <br /> ifHI ft.after L hrs.pumping � g.p.m. <br />' WELL HEAD COMPLETION .� � <br /> Well owner's mailing address if different than property owners address indicated above. dless adapter manufacturer_ °�s.`�.-�G-....�_r�..�._s^��+MedW <br /> �asing Protection �12 in.above grade <br /> �At-grade(Environmental Wells and Boring ONLY) - <br /> GROUTING INFORMATION <br /> Well grauted �Yes ���:����No <br /> Grout material i Neat cement ❑Bentonite ',_Concrete �1 iigh Solids Bentonite <br /> from Q to 3Q n. 3 ❑yds. �Dags <br /> from�to�ft�4��__���Is. �bags <br /> - GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to_ ft. �'�yds. [bags <br /> MATERIA� <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> �.� <br /> �l�g �i� ��� O 15 feet � direction type <br /> .�, Z " <br /> Well disintected upon completion Yes ❑No - <br /> C� 5��� �r �J PUMP � <br /> i � � :�� <br /> ❑Not installed Date installed � <br /> �/ t$�� b�� �1�$ 9J 7V� Manufacturer's name `-.�.t�+-.;�1...^...�.+-, ---".,'.".�„`__--• <br /> Model number HP � <.. Volts � y <br /> (.`I j�i� � I$� Length of drop pipe f��� ft. Capacity g.p.m. <br /> Type:__� ubmersible � �LS.Turbine ❑Reciprocating ❑Jet ❑ <br /> �fK1/ . I br�� �f� ��� 2� ABAN ONED WELLS � <br /> Does property have any not in use and not sealed well(s) ❑Yes o <br /> VARIANCE <br /> Was a variance granted from the PADH for this well? r_'��Yes � o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,il needed <br /> � REMARKS,ELEVATION,SOURCE OF DATA,etc. � �fi_.�`�� �3• Y1�111 jn�. �.� T�' +fY1 T�f <br /> IJC�J 1.L 11LJ.i3i..,E� i 4/3/4 <br /> Licensee Business Name Lic.or Reg.No. <br /> f � . � �� <br /> � <br /> A i s2nfefive gnature Date <br /> �b �s <br /> �. � ���� � Name of Oriller <br /> LQCAL COPY HE-01205-OB(Rev.S/02) <br /> ic,ao-oozo <br />