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x <br /> � � .� � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> Counry Name � WELL AND BORING RECORD 6 2� 9� 9 <br /> Henn�pi n Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 118 23 31 :. . . 25Q• " 7-19-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 165 Luce Line Rf��e Road Ot� 0� �'♦ ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well bCation. ❑ <br /> Showing property lin�s, �� <br /> roads and buildings: � DRILLING FLUID WECL i�YDROFRACTURED? ❑YES ❑NO �� <br /> " .$entonite <br /> i i � i FROM. , ft.to ft. <br /> __ _i_ _-_ _i_ <br /> USE ❑ Monitoring 0 Heating/Cooling <br /> i i i � �.Domestic ❑ Communit PWS <br /> _i_ _a_ _i_ _i_ � Y • � p.�ndustry/Commercial <br /> � i i i ❑ Irrigation ❑ Noncommunit PWS <br /> `N E <br /> �� ❑ Environ.Bore Hole y Q fl8f�'i@dial <br /> i i i i 1/�E• , ❑ Dewatering ❑ . <br /> -r -�- -r- -r T x . -- <br /> i i i i ,�zM�e CASING - �� Drive Shoe? ❑ Yes No . HCS�E'DIAM. <br /> _i_ _ i_ _i _ _i_ ❑ Steel �.'O Threaded ❑ Welded � <br /> i i i i <br /> � l I�Plastic ❑� _�i t;� <br /> g <br /> �-iMile� ������ G/�w� . <br /> i CASING DIAMETER WEIGHT �� sF�'�.' <br /> PROPERTY:OWNER'S NAME � in.to 2�Z R. Z�Q� Ibs./ft. {�,ta 3� n. <br /> Joe � Stephanie Church ;�.,o ft. Ibs./ft. �;�.,025�. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. ���� Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE � � <br /> Make 0 ns0� from___. tt.to ft. <br /> Type Stainless .CltEB'�. Diam. <br /> SIoUGauze .Q I p Length 8� <br /> Set between 2�2 ft.and�_ft. FITTINGS: Z~ x �O�w!k <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 1 4 Q� ft. �below ❑ above land surface Date measured����q <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if difterent than property owner's address indicated above. 1 3�] ft. after ,2 hrs.pumping 1$ a�,L g.p.m. <br /> YWELL HEAD COMPLETION <br /> nl Pitlessadaptermanufacturer TAT�If t�WBtE.'rModel <br /> ❑ Casing Protection �12 in.above grade <br />• ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORM+A�TION <br /> Well grouted? �4J Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat ceme t ❑ Bento ite ❑ Concrete yi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO (� 3f� 2�7 y <br /> from to V ft. • ❑ yds.f? bags <br /> Op Soll B1�Ck S d• 2 1 from co n. ❑ Yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAR6s��c N SOURCE OF CONT INATION �,l��j"�iC <br /> �.3�/ Ye 1 I c� $ �� 3� / �� teet ��Jn r� direction "�"� type <br /> Well disinfected upon completion? [�[Yes ❑ No <br /> and Clay Grey M 3$ 220 pUMP <br /> 7-2Q-99 <br /> ❑ Not installed Date installed <br /> lay Gravel Brown M 2�U 240 HOMEOh�tE <br /> Manufacturer's name <br /> a��' E LrQar��'� �1„dWTl 5• ,Z4� 25Q Modelnumber HP votts <br /> Length of drop pipe g v� ft. Capacity g.p.m. <br /> Type: Q'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 O-No TN# <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 /> DON STC3DOLA �v'ELL DRILLI�iG C0. , IIdC. <br /> Lice ee Busine Na Lic.or Reg.No. <br /> 8-26-99 <br /> Authorized�rtsentative Signafure Date <br /> Chuck Moore 7-19-99 <br /> - F <br /> 6�4 9 4 9 Name olOril/er Date <br /> LOCAL COPY HE-01205-06(Rev.7/98) <br />� <br />