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_.� <br /> �� <br />� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO. <br /> County Name WELL AND BORING RECORD <br /> Minnesota Statutes, Chapfer 1037 �� ��� � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. ��J <br /> �� �� '� � �—ll�'} <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds I-I Cable Tool i.��,Driven �:_i Du <br /> Longitude degrees minutes ____ seconds 9 <br /> L I Auger .�yFtotary �'Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � j�• <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Show exact location of well in sec[ion grid with" ". Sketch map of we!I location. ��e� FROM ft TO ft. <br /> Showing property lines, <br /> N roads and buildings USE �-, <br /> ___s [Monitorin <br /> g [�Heating/Cooling <br /> � � � � _ k Domestic ��Industry/Commercial <br /> ______ ________ __ _ �]Environ.Bore Hole <br /> � � Noncommunity PWS �Irrigation �]Remedial <br /> I I I I - ' unity PWS ❑Dewatering <br /> `� Comm [� <br /> --'-- --�-----�-- ---`-- <br /> W i i i i E� ASING Drive Shoe? �Yes �]No OLE DIAM. <br /> ,�_.._..� �. C H <br /> --�--- --;-- --�-- --%- e_r,A {,t.�E el hreaded�••.❑Welded <br /> , ; ; , '/nniie j. �' lastic _ <br /> �S �T <br /> P ❑ <br /> , � � , �T <br /> ------ ------ --.-- --.- 1 <br /> � � � � CASING DIAMETER WEIGHT <br /> � � S � � � <br /> �1 Mile—� .,i.. �in.to�_ft. __ il _Ibs./ft. �in.to_,�ft. <br /> �•� in.to_ fL . __Ibs./ft �.in.to�Qft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to tt. Ibs./ft. n.to�ft. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make FROM�Q ft. TO_ 6.�L ft. <br /> � 8$ $y,� Type Diam. <br /> [AIYC <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL e� � <br /> �� fC below ❑above land surface Date measured ` '� <br /> PUMPING LEVEL(belbw land surface) <br /> WELL OWNER'S NAME/COMPANY NAME x 4� <br /> ��O ft.after v hrs.pumping w g.p.m. <br /> WELL HEAD COMPLETION 1 <br /> Well owner's mailing address if different than property owners address indicated above. itless adapter manufacturer l..t�7�� t.k..7 d��d� Model <br /> �asing Protection �2 in.above grade <br /> J At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> '� , Well grouted �Yes '._,�No <br /> Grout material ' [J Neat cement ❑Bentonite [I Concrete�High Solids Bentonite <br /> from_�to_�_ft. �.__ '_yds. �ags <br /> from�' _to�" �_ft�.����is. I]bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. � <br /> MATERIAL �J yds. ❑bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> i-f r..� <br /> `�_.�': feet � direction -�:-:��- �.�-+� type <br /> Well disinfected upon completion Yes ❑No <br /> PUMP <br /> �.' �" � <br /> ❑Not installed Date installed - +.j ' (1 <br /> Manufacturer's name � '-r <br /> Model number HP�Volts '� �w�� <br /> Length of drop pipe f�Jw,i ft. Capacity g.p.m. <br /> Type: Submersible ❑L.S.Turbine � I Reciprocating ❑Jet '�] <br /> ABA DONED 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 well7 ❑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,if needed � �taiola �e12 Iarilling Co,. Il�(.`• �717G <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Business Name ' Lic.or Reg.No. <br /> .- `/ � �`� <br /> o e ta -A.�� re � Date <br /> Ctnick Moare 3-4-04 <br /> 7 � � ��� Name of Driller <br /> LOCAL COPY He-o,zos-oa�ae�.aioz� <br /> ic iao-oozo <br />