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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> CountyName WELL AND BORING RECORD <br /> Hennepi n Minnesota Statutes Chapter f03/ 5 915 0 9 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117 23 3b SW SW Sw i40 n b�25�g� <br /> �,. �,. �,. <br /> House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> �0 M rtlewood Road ❑ Cab�erooi ❑ oriven ❑ oug <br /> ❑ Auger C�Rotary ❑ Jened <br /> Show exact location ot well in secUon grid with"X".� Sketch map ot well location. �; ___ .._____ _ <br /> � Showing propeRy lines, <br /> roads and bwldings. DRILLWG FLUID <br /> , " � water <br /> -,- -,- -r- -,- <br /> USE � ❑ Monitoring ❑ Heating/Cooling <br /> i i i i <br /> i � � i ❑ Community PWS ❑ Industry/Commercial <br /> i i � � j C�Irrigation ❑ Noncommunity PWS ❑ Remedial <br /> w e-r � ❑ Test Well — <br /> � � � i � ❑ Dewatering ❑ <br /> � <br /> i i r r �/zIM e CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _, , i ,_ � ❑ Steel ❑ Threaded — ❑ Welded <br /> ,- -�- -, - -, <br /> []�Plastic ❑ <br /> �tMna� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �in.to�,�fl. Z00 Ibs.11f 3/ �in.to �I tt. <br /> Karen Proft in.to ft Ibs/ft �;�.,�n. <br /> Property owner's mailing address if diNerent than well location address indicated above. — .in.to ft. Ibs./ri. in.to__tt. <br /> SCREEN OPEN HOLE <br /> Make.?a'V C_z___� from ft.to (1. <br /> Type FVC Diam. _T <br /> SIoUGauze �Q Length 7� <br /> Set between �Z�fl.and �an .ft. FITTINGS:K, Paeker <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME �J7 ft.� below ❑ above land surtace Date measwed �CJ �7 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than propeRy owner's adtlress indicated above. � R. afler � hrs.pumping 5��' g.p.m. <br /> WELL HEAD COMPLETION <br /> ]t7 Pitless adapter manufacturer Model <br /> ]Q Casing Protection 3�] 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted?�[] Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Giout Material ❑ Neat cement ]p eernonite ❑ Concrete ❑ High So�ids Bemonite <br /> MATERIAL 1 <br /> from�L to�tt. 8 ❑ yds.Xl bags <br /> �Q''jJ $dj], black ��d• � 1 from to fl. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. O bags <br /> (�`la bro�n �ed• 1 19 NEAREST KNOWN SOURCE OF CONTAMINATION <br /> X �35 feet _ � directionSe�t'.1C �� <br /> Well disinfected upon completion? ]�Q Yes ❑ No <br /> sandy clay blue med. 19 42 pUMP 7 <br /> ❑ Not mstalled Date install d 7�1�97 <br /> $711C� b gravel IAj.X IC1eC�• 42 S9 Manutacturer'sname St3-R�te <br /> ModelnumberS50M HP 1/2 vous 230 <br /> sandy C18y lU@ Bled. 59 120 Lengthofdroppipe 8� tt Capacity gpm. <br /> Pressure Tank Capacity___��_ <br /> Type: �Submersible ❑ LS.Turbine ❑ Reciprocatulg ❑ Jet ❑ _ <br /> sand S. c�ravel vhiLe 12p 1�1 ,� <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes l�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes l�No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il 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 /> RES Well Drillin� 27276 <br /> Licensee Business Name Lic.or Reg.No. <br /> .� <br /> ' �� �,^ / / ' <br /> _ ;�`� .':�: f,!' �'"�;��r_� __ `7 / �l <br /> Authorized Representative Signature Da e <br /> Robert E. Stadola, Jr. 7/1/97 <br /> Name ol Driller Dafe <br /> LOCAL COPY 5 915 0 9 „E-0,zo�5,�.�.,;�5> <br />