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_ _ . �� <br /> ' WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> .' County Name WELL AND BORING RECORD ,. <br /> Aec�pin Minnesota Statutes,Chapter f031 � � �g� � <br /> ��� Township Name Township No. Range No. Section No. Fraction �. WELL DEPTH(completed) � Date Work Completed <br /> ? fl. { <br /> �� �� '� l ���J <br /> � GPS Latitude degrees minutes seconds _ DRILLING METHOD <br /> � LOCATION: � <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 /> DRILLWG FLUID WELL HYDROFRACTURED? �Yes � o <br /> � Show exact location of well in section grid with"X". Sketch map of well location. � �t� FROM ft.TO ft. <br /> Showing property lines, <br /> � N �� roads and buildin� USE Domestic � �Environ.Bore Hole I��Heating/Cooling <br /> ' ' � � � � Y l] 9 �Industry/Commercial � <br /> Monitorin <br /> ' '--- --'-- `-- —`- � <br /> -�� I Noncommunit PWS �,Irri ation Remedial <br /> _ I I I I _ munity PWS ;Dewatering ❑ <br /> ,�y Com [ <br /> --'----,------`—--`-- / <br /> < CASING HOLE DIAM. � <br /> � -�- - ---1— ,h M�ie -)�' � �.:�� �y�c..,:.•�Plastlic �i Threaded � L s �No . <br /> w E ` Drive Shoe� Ye <br /> __ �- � ,Welded <br /> � I �J ,., . <br /> . . . 1 :. : <br /> � ' S � � �.` CASING DIAMETER WEIGHT <br /> i .� ' � \, �__.in.to 1Q5 fl. 2�� IbsJft. �in.[o__�ft. <br /> i 1 Mile—� _ <br /> in.to _.__, ft. , __ Ibs./ft. �in.to1.1.�ft. <br /> :RROPERTY OWNER'S NAME/COMPANY NAME <br /> in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> '.Property owner's maihng address if different than well location address indicated above. Make <br /> --���}$��-- FROM ft. TO ft. <br /> � Type_�����_ Diam._ �yw _ _ <br /> SbUGauze��,_ __ ,Length�� _�� <br /> Set between ft.and tt. FITTINGS'i}` i� <br /> STATIC WATE EL • <br /> ft.�below [�above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> ft.after hrs.pumping g,p.m, <br /> p WELL HEAD COMPLETION <br /> � Well owner's mailing address if ditterent than property owners address indicated above. i }-�� y <br /> �Pitlessadaptermanufacturer ;.._�.:��k,�. ?;-��_�*.'�.J"�'-Model <br /> .Casing Protection �JC12 in.above grade <br />"" ��=�At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted �Yes r�No <br /> Grout material ❑Neat cement r 1 Bentonite ��Concrete Q�High Solids Bentonite <br /> from_�to,��ft. �__ ��_yds. �ags <br /> from_'�__to_���ft. �����y�� �� bags <br /> GEOLOGICAL MATERIALS COLOR H MAT RSA OF FROM TO from to ft. �..J yds. ❑bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION .i <br /> ���y-a.-.J l y <br /> ~ _J feet f''J direction '�� ::u�ype <br /> Well disinfected upon completion Yes J No ��,_,-..,.,,��,�.� ,�„�. �;�y,,;;,,.�,� <br /> PUMP <br /> � i�]Not installed Date inslalled -^ ..7 "'` <br /> Manufacturer's name � �..�c_.__ �--�._S"�-F-���^-� <br /> � Model number HP f Vol[s �-tJ <br /> Lenyth of drop pipe �..�j�r ft. Capacity g.p.m. <br /> Type:�'. ubmersible ❑L.S.Turbine r��.Reciprocating �','Jet LJ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) �;Yes �i No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? [j Yes �Jo 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 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. �a•T��. ����^ <br /> 6 <br /> Licensee Business Name Lic.or Reg.No. <br /> i <br /> i <br /> �V <br /> epresentative Si ature Date <br /> .. 4l H� ��Q' <br /> LOCAL COPY f NameofDriller <br /> 71 ��� 9 <br /> HE-01205-OB(Rev.5/02) <br /> IC 140-0020 <br />