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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL QND BORING RECORD � <br /> Minnesofa Sfatutes, Chapter f037 � � � ��-¢ � s� <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Q6 �� �� �� 105 " 3-16-Q6 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds . <br /> Longitude degrees minutes seconds i-'i Cable Tool �J Driven �_j Dug <br /> — _�Auger ,r�Rotary �]Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �-� <br /> DRILLING FLUID WELL HYDROFRACTURED? ,_i Yes �No <br /> Show exact location of well in section grid with"X". Sketch map of well bcation. �te�► FROM tt.TO tt. <br /> Showing property lines, <br /> N 9 <br /> {. � roa s an w in s E �En ironl Bore Hole � Heating/Cooling <br /> � _._____---�"��� h �.�t s r� D <br /> ' ' ' � � [�Domeshc Ty ❑ g �I Industry/Commercial <br /> --'-----'------`---`-- <br /> j j j j � rl Noncommuni PWS Irri ation i Remedial <br /> 1 I ; ; � `t ,,,��""'^- �Community PWS ❑Dewatering �J <br /> --'--- --i--- ---;-- ---`- <br /> � � � : Y#' CASING <br /> w ; ; ; ; e T � Drive Shoe? �, �Yes � o HOLE DIAM. <br /> � <br /> --;--- --;----�-- ---;-- I �_J Steel �_`J Threaded �'� ���Welded <br /> 'h Mile 18StiC _ <br /> � �� __.__- - <br /> --;-----'------f-----�-- 1 CASING DIAMETER WEIGHT <br /> S �in.to_���_�ft. 2 s W IbsJft. S7 in.to -�Jt. <br /> �—,M,�e� ---- 6 5 10�,. <br /> in.to ft. Ibs.fft • in.to <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make tiA�� FROM ft. TO � ft. <br /> c/c�Grant Wenketern Type �s..��.4....s$t�_ Diam.� <br /> 71� �rt� ����' �r � � SlobGauze__��y�__ Length /t_� L� <br /> 47t IV if 1 V —�"F-- <br /> s�T 'l Set between _tt.and it FITTINGS <br /> �� ,�'�v ����T STATIC WATER L <br /> � �� 3!.� elow ;-��above land surface Date measured .7-1lJ�lJV <br /> PUMPING LE'C�L(below land surtace) <br /> WELL OWNER'S NAME/COMPANY NAME . -- �,,,. �'-� ' <br /> �~ - ' �� ft.after �,�� hrs.pumping 13 g.p.m. <br /> WELL HEAD COMPLETION � <br /> Well owner's mailing address if different than property owners address indicated above. -Y <br /> itlessadaptermanufacturer 'u1.��.' _ -��=_�-r--�Model <br /> � <br /> -� � _'Casing Protection I�2 in.above grade <br /> � -- ;At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted-� I�Yes []No <br /> Grout material ❑Neat cement ❑Bentonite i=�Concrete I-SVI-ligh Solids Bentonite <br /> from_�to�g�ft _� [_;yds. r�bags <br /> from__�to_�Z�,�t. �$��J����,bags <br /> HARDNES OF FROM TO � hom__ to ft. � ��� ds. ' ��ba s <br /> GEOLOGICAL MATERIALS COLOR tijATER AL —Y 9 <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> �..r.. / � � <br /> _ �;,;,, feet I.AJ direction i�-a�._�. type <br /> Well disinfected upon completion �,Yes !=,�No � <br /> PUMP <br /> ;Not installed Date installed "� �'��J v� <br /> Manufacturer's name � '.J�-�_-`.• •'�•.1�`�+-��'�--- <br /> Model number HP�Volts -� �.�r� <br /> Length of drop pipe �4 tt. Capacity g.p.m. <br /> Type:[ ubmersible ❑LS.Turbine ❑Reciprocating [_i Jet r� <br /> ABANDONED 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 if 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,il needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. ��r(�ALA We11 �?rj I7 in� ��' �(�`• L71TG <br /> Licensee Business Name Lic.or Reg.No. <br /> i <br /> � I� :.�/ ���o <br /> A z s tati e Signature, Date <br /> C�AtCIC Mi00C@ <br /> LOCAL COPY � �y ��� � NameolDriller <br /> �3 HE-01205-OB(Rev.5/02) <br /> ic�ao-oozo <br />