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. � <br /> � - <br /> � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name � WELL AND BORING RECORD 6 2 4 9 7 9 � <br /> �iennep i n Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Sgction No. Fraction WELL DEPTH(completed) Date Work Completed <br /> fl. <br /> r�� � 'I< 'l. 'l. � <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 'rJ�7 Fernda C� R aa • ❑ Auger �l Rotary ❑ Jetted <br /> : <br /> Show exact location of well in section grid with"X". Sketc map of well location. ❑ ___ _ <br /> S owing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES C NO <br /> N <br /> , , , , Wa t e r FROM n.to n. <br /> -,- -,- -,-- -,- <br /> - USE ❑ Monitoring ❑ Heating/Cooling � <br /> i i i i x �l Domestic ❑ Communit PWS <br /> _i_ _�_ _x_ _i_ Y ❑ Industry/Commercial <br /> i i i i „l`�� ❑ Irrigation ❑ Noncommunit PWS <br /> W E T W L ❑ Environ.Bore Hole Y ❑ Remedial <br /> i i i � ❑ Dewatering n <br /> i i i i +ZIM_ie CASING Drive Shoe? O�es ❑ No HOLE DIAM. <br /> _i_ _ i _i_ _i_ I � Steel Z(I Threaded ❑ Welded <br /> � �- � � 1 <br /> ❑ Plastic ❑ <br /> S <br /> �-1 M�ile--I <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME { 4 in.to �17�n. ibs.in. 7�,5� 30n. <br /> X"�� �dJ.��d i in.to ft. Ibs./tt. 1 in.to�.�ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. �,��F�{�. <br /> SCREEN OPEN HOLE w <br /> Make_�� from �1 7 ft.to �"�5 ft. - <br /> Type Diam. <br /> SIoUGauze Length <br /> Set belween ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME g�� ft.1X below ❑ above land surtace Date measured ���3�99 <br /> PUMPING LEVEL(below land surtace) <br /> Well owner's mailing address if different than property owner's address indicated above. 2�S� ft. after 5� hrs.pumping 4� g.p.m. <br /> WELL HEAD COMPLETION �i��W�te r <br /> �J Pitless adapter manufacturer Model <br /> ❑ Casing Protection � 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMyATION � <br /> Well grouted? '`�7 Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement � Bentonite ❑ Concrete �High Solids eentonite <br /> MATERIAL <br /> from_�_to_�Q_ft. �_'�___ ❑ yds.�(1 bags <br /> from to ft. ❑ yds. ❑ bags <br /> 5 <br /> Cla -Gravel Y�LZ�� � from to R. ❑ yds. ❑ bags <br /> NEARE9'Ff N SOURCE OF CONT�AMINATION � <br /> Cla Gre S 20 $5 { J feet Y--311✓� � direction �^�i ' ��"' rype <br /> Well disinfected upon completion? f+J Yes ❑ No <br /> Cla Grav�l Arown S g5 �,g PUMP 9_9_9g <br /> ❑ Not installed Date installed <br /> t.'Ic3 Gre S 1 rJ0 190 Manufacturer'sname GOu'ld <br /> Modelnumber Z'92111972 HP 1'� vorcs �30 ��' <br /> Sand Tan S 19fl 2�.5 Length of drop pipe 147� ft. Capacity �'2 g.p.m. <br /> y Type: 49 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> Sandstone varied M �d � ABANDONEDWELLS y <br /> Does property have any not in use and not sealed well(s)? ❑ Yes t?No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes 1�No TN# <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 /> DON STODOLA WELL DRILLIAIG CO. , INC. <br /> Licen Business N e c.or Reg.No. 2'�I'�2 <br /> r <br /> � <br /> � 9-15-99 <br /> Authorized Reprp�sen �ve Signature Date <br /> Fred L�*iby 9-5-99 <br /> Name ol Driller Date <br /> LOCAL COPY 6�L�.9 7 9 HE-01205-06(Rev.7/98) <br />