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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 5 9 Y 5 4 3 <br /> 11�11118 lA Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orc�no 118 "l3 %� �i ,�E,,.SW ,. ��E3 " b/1"l/�8 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> c- C7 Cable Tool ❑ Driven ❑ Dug <br /> �UCI Hui,ter Par�s <br /> i7 Auger �] Rotary ❑ Jetled <br /> Show exact loca6on of well in section grid with"X". Sketch map ot well location. ,� _ <br /> ShowmgpropertyGnes, ��� -���-� ��- � � <br /> roads and bu�di s. DRILUNG FLUID <br /> " �" �3�ntoni t� <br /> � � � � <br /> -,- -,- -r- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> , i i , }�[7 Domestic ❑ Communit PWS <br /> _i_ _�_ _i_ _i_ � ❑ Irrigation Y ❑ Induslry/Commercial <br /> � � � � �'� � - ❑ Noncommuniry PWS ❑ Remedial <br /> w e T � ❑ Test Well <br /> � � � i • ❑ Dewatering ❑ <br /> � � i � ,/zIM< ,,,.�, '� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _i_ _i_ _I_ � `��T � � 4'"'��„� r��.. '� ❑ Steel ❑ Threatled — ❑ Welded <br /> �I i ,�,...-.�-.�.�.^� �i Plastic ❑ <br /> S �.T....r�r�...�..,..... <br /> �-t Miie-� <br /> CASING DIAMETEA WEIGHT <br /> PFOPERTY OWNER'S NAME _______�_in.to_�_�tt. Ibs./R. � in.to ��ft. <br /> J ylan� H���S in.to ft. Ibs.ttt. ���,t��ry. <br /> Property owner's mailing address if diHerent than well location address indicated above. in.to ft. IbsJft. in.to ft. <br /> 2�� E• LdK$ S C• SCREEN OPEN HOLE <br /> �Fj�2c�ta� j� rj�,s�l Make � ,1,�,_F from ft.to ft. <br /> TYPQ .y� ,j�l:rt�N Diam. <br /> SIoVGauze�_Q_ __.___ Length 1(�/� <br /> Set between Z 1 j3 ft-and 1�� _fl. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME �7 ft.�below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) 1 <br /> Well owner's mailing address if diNerent than property owner's address indicated above. 1�V tt. atter l hrs.pumping J� g.p.m. <br /> WELL HEAD COMPLETION <br /> 7�i Pitiessadaptermanutacturer �hltE3t�Td�.@� Mode� `S���y <br /> O Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? � Yes ❑ No <br /> HARDNESS OF Grout Matenal ❑ Neat cement ❑ eentonite ❑ Concrete ."O High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from � to �� tt. 3 ❑ ytls. �bags <br /> from .3� to 1�� ft. ❑ yds. ❑ bags <br /> ��}� ��11 r3.�cl�i� S(.7�rr y 3 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> l:,1,d17 YjrV�yrj ���� � i� �L feet Yi�t$� direction$t3iiiSlt�� rype <br /> Well disinfected upon completion? f�Yes O No <br /> ciaf C�y.`tc�� 3���. 1� �L PUMP <br /> C Not installed Date installed 7�l�g�'i <br /> ,5�311Q �e �Y'dVCl �X p]�(j. �L C�(j Manufacturer'sname `�La'�KYt� <br /> Model number _ ,�s HP��_ Volts �.3� <br /> Lengih of drop pipe j 4 V tt. Capacity� L(j g.p.m. <br /> "llt ciay yray Si)f� gb LL1 pressureTankCapaciry L�V __. <br /> Type� �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> <inn ix ,�o�t lti L4t3 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes f�No <br /> VARIANCE <br /> Was a variance qranted from the MDH for this well? ❑ Yes 0.'No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/needed This well was tlrilled 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 /> RES Well Drilliny .�7�76 <br /> Lrcensee Business Name Lic.or Reg.No. <br /> � � <br /> � � .� � <br /> .�/�.",--.+�q/ ! �� .s+"-" � 7 / <br /> Authonzed Representative Signature Date <br /> J tiI�12 Fa 1.�:� <br /> Name ol Driller Date <br /> LOCAL COPY 5 915 4 3 HE-01205-05(Rev.1/95) <br />