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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD �, � 2 6 8 2 <br /> H e n n z�i n Minnesota Statutes Chapter 103/ <br /> Township Name Townshi No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 7 SW SW SE 111 " lU/18/36 <br /> ��. ��, ��� <br /> House Number,Street Name,City,and Zip Code ot Well Location or Fire Number DRILLING METHOD <br /> 4174 Hit�.hwood Road ❑ CableTool Q Driven ❑ Dug <br /> ❑ Auger L�'Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> /� j� Showing property lines, <br /> / �� roads and buildings. DRILLING FLUID <br /> " r-�-�� water <br /> � � � � <br /> � � -,-- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> _i_ _�_ _i_ _i_ [�Domestic ❑ Community PWS ❑ Industry/Commercial <br /> � � i i , ❑.1�rrigation ❑ Noncommunit PWS <br /> L�`��`t�L�_ Y ❑ Remedial <br /> vd i i i e � ��West Well ❑ Dewatering ❑ <br /> -r -�- -r- -r T <br /> i � i i �/2M.ia �/ ��� " CASING ^ . Drive Shoe? ❑ Yes o HOLE DIAM. <br /> _i_ _i_ _i_ _i_ � ^ " � ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> C�Plastic ❑ <br /> S <br /> �1 Mile� .�....�. <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME `� in.to 1�� ft. ��� Ibs./ft. �a���o_6�. <br /> ��r k` ������ in.to ft. Ibs./ft. v"� in.to j 1�. <br /> Property owner's mailing address it different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> 17605 Susan Driv� SCREE OPENHOLE <br /> Mif'netonk�, M� ���4�J Make aY from ft.to ft. <br /> Type Diam? <br /> SIoUGauze Length � <br /> Set between tt.and it. FITTINGS: <br /> STATIC WAT�i�EVEL 7� <br /> WELL OWNER'S NAME � ft.-�I below ❑ above land surface Date measured <br /> PUMPING LEY�,6,(below land surface) 3 �� <br /> Well owner's mailin address if ditterent than ro e �V <br /> g p p rty owner's address indicated above. ft. after hrs.pumping g.p.m. <br /> �LLHEADCOMPLETION whitevater S�LJ�4 <br /> Pitless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMA1TION <br /> Well grouted? V Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat ce e C'xBen onite ❑ Concrete ❑ Hi h Solids eentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �� � 9 <br /> from to ft. ❑ yds. ❑ bags <br /> c 1 a y L r u w n _r.��. 0 3 6 ''°"' _�� n. ❑ vds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KN �jN SOURCE OF CONTAMINATION <br /> �li�:� "`lU:-' I:1�C�. 3�1 �5 �" feet 7� N direction �e��'r type <br /> ��X Well disinfected upon completion? '2J Yes ❑ No a i r t e$t�� <br /> sand brown fiii� 6� I11 PUMP 10/24/56 <br /> ❑ Not installed Date installed <br /> ManufactureYs namg �t r3—R 1�t� <br /> Model number 1�� HP ioSs � <br /> Length of drop pipe ft. Capacity U g.p.m. <br /> Pressure Tank Capacity <br /> Type: C�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> ABANDONED WELLS y <br /> Does property have any not in use and not sealed well(s)? ❑ Yes 'fl No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? � Yes ❑ No <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 /> 12.E.5. Wel.l Drillin� 27"L76 <br /> Licensee Busmess Name , Lic.or Re .N. <br /> r <br /> 2�-r�' �. ��'�_.,/� �.�d_f<-._ rf �`/17 G <br /> Authorized Representative Signature Date <br /> Robcrt �,. Stodala, Jr. 10/24/95 <br /> Name of Driller HE 01205-OS(Rev.1/95) <br /> LOCALCOPY 5726 �2 <br />