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--� � w <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> �o��,y N�me WELL AND BORING RECORD <br /> ��p�.n I'Ainnesota Statutes,Chapter 103I � ��� � � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> o� ii� z3 0� tt <br /> ,, ,, ,, <br /> . GPS DRILLIN6 METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds �� �Cable Tool ��-]Driven �Dug <br /> ��Auger �Rotary �,_,Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� <br /> .t DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �1Vo <br /> Show exact location of well in sectio grid with'X". Sketch map of well location. �ter FROM fL TO ft. <br /> ..--��� Showing property lines, <br /> : N -�'s roads and buildings USE - . � � ;� <br /> � ^- `� []Monitonng L;Heating/Cooling . <br /> � � � � t(�. j�Domestic ❑Environ.Bore Hole ��r';Industry/Commercial <br /> --'----'--- ---`-- ---`-- <br /> �� �,�� . `__-Noncommunity PWS n Irrigation —'Remedial <br /> � Community PWS ❑Dewatering <br /> ' --i----'--- --`-- ----- <br /> : <br /> � w ; j ; ? E . ` ASIN Drive Shoe? Yes ❑No � OLE DIAM. <br /> C G H � <br /> ' , r r 'h nniie �( `LJ Plastic �Threaded�❑Welded . <br /> ' � � � � 1 � CASWG DIAMETER WEIGHT ` <br /> ; ; S � k <br /> ��'� __�__in.to _2Z�ft. �,1 Ibs./ft �in.to�t. <br /> s �1 Mile —� <br /> . in.to .. ___ft IbsJft �in.to��ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAM � in.to ft. Ibs./R. .to <br /> 's SCREEN OPEN HOLE <br /> Proper?y owner's mailing address if different than well ocation address indicated above. Make � <br /> FROM ft. TO ft. <br /> t�79t� Lunski i.ane Type Diam. <br /> '�t 55347 SIoVGauze Length <br /> F.�c}en Praicie, r Set between ft.and ft. FITTWGS <br /> STATIC WATER LEVEL <br /> �I ft. below �j above land surface Date measured���I <br /> PUMPWG LEVEL(below land surface) - <br /> � WELL OWNER'S NAME/COMPANY NAME <br /> 1�� ft,after � hrs.pumping �O g.p.m. <br /> W LL HEAD COMPLETION � �(� t � <br /> Well owner's mailing address it different than property owners address indicated above. Pitless adapter manufacturer 1..�-�'*�-`�..�-f"�`�"^— Model_ <br /> J Casing Protection 1�12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> ,�. GROUTING INFORMATION <br /> Well grouted es ❑No <br /> Grout material �eat cement [;Benronite ❑Concrete�High Solids Bentonite <br /> from__Q_to___�ft. �_ �:yds. �.bags <br /> from__ �to_'��tt. ��� �risl ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to_ ft. _ []yds. �'i ba s <br /> MATERIAL 9 <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> C�a� b�� .�ft � 1� J�'� feet � �1� direction ,J".-'s ra-' ,=' �e <br /> Well disinfected upon completion Yes ❑No :_�_,,,a„" -„�,� ��.U��..: � -�; <br /> C18Y Or`�Y SOlt 12 YV PUMP ! ,._-....� f.'�-_..� �.ly.o..r.�. <br /> ) `../v `�.) <br /> ',Not installed Date installed �.! J <br /> S$1]d �CSy $Of t �i �Manufacturer's name �.�L—N�'�.�' — <br /> * Madel number HP / Valts " .✓� <br /> Cl$y,� �i�y `��t � 275 Length of drop pipe �`�' ft. Capacity g.p.m. <br /> y,,� Type:, �Submersible ❑LS.Turbine ❑Reciprocating ❑Jet �_J <br /> 1f1I'�SCO� � iY�� 27S ZSS qgqNDONED 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 MDH for this well? ❑Yes No 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,if needed � �t y�II �11 �1.,.j 1 7 j n{ , <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. . C7pU 11 aiLiyli��t� � . z� Zn�t <br /> Licensee Business Name Lic.or Reg.No. <br /> j /` � . �� <br /> epr entative 'nature Date s <br /> W l�ll:.� �� <br /> 7 �� ^ �y� Name ol Driller <br /> �.00AL COPY T L <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />