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<br /> - WEL�LUCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO.
<br /> �� County Name WELL AND BORING RECORD {,,
<br /> �p� Minnesota Statutes, Chapter f037 ^r ��� � �
<br /> � Township Name Township No. Range No. Section No. Frection WELL DEPTH(completed) Date Work Completed
<br /> ' �1D 117 Z� � y, y i 1�0 n �d"'�"'(�
<br /> GPS DRILLING METHOD
<br /> ' LOCATION: Latitude degrees minutes seconds _�� .
<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 /> � �;"�� � �" �!"�� �5� DRILLING FLUl�trl}e WELL HYDROFRACTURED? ❑Yes I o
<br /> � Show exact location of well in section grid with"X". Sketch map of well location. «�16
<br /> Showing properry lines, FROM ft TO ft.
<br /> N roads and buildings USE
<br /> . [�Monitoring ��'���Heating/Cooling
<br /> _ ___ _ _ _ `� �Domestic ❑Environ.Bore Hole �J Industry/Commercial
<br /> .� : :_. :
<br /> i J i i ��� LI Noncommuniry PWS '-�Dewaterin , Remedial :
<br /> ��Irrigation �
<br /> � Community PWS �_; g .. 'i_.
<br /> -�` CASING HOLE DIAM.
<br /> 2 w , , e T -��� ive Shoe? Yes j�No �
<br /> � •
<br /> Dr
<br /> '. ,--- - ; _�-- -;-- I `�-*� f�Steel � j Th�eaded �,Welded '
<br /> 'h Mile lastiC '� ]
<br /> --
<br /> --,--- --.-- � -�-- 1 =� .
<br /> CASING DIAMETER WEIGHT
<br /> S ' ' 1 �.
<br /> , � `1 in.to �� ft, ���� . IbsJfL �in.to r�
<br /> i 1 Mile� — - �.
<br /> in.to__ _____ft. Ibs./fL �in.to ��
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.�o ft.
<br /> `xiAL�}T� FfBt� SCREEf�.,f_._�,� OPEN HOLE
<br /> �� Property owner's mailing address if different than well location address indicated abova �������
<br /> Make� FROM M_ft. TO ft.
<br /> � � aW�' TYPe— ��� -_—__ Diam. -_ —
<br /> SIoVGauze_ �y'+� Length�����f�
<br /> Set between�ft.and�_ ft. FITTINGS�__�Y �
<br /> STATI��ATER LEVEL ����5
<br /> ft. elow [1 above land surface Date measured
<br /> PUMPING LEVEL(below land surface)
<br /> ' WELL OWNER'S NAME/COMPANY NAME
<br /> 1� ft.after_ 2 hrs.pumping��__ g p m �
<br /> WELL HEAD COMPLETION �
<br /> �. Well owner's mailing address if different than p�operty owners address indicated above. �itless adapter manufacturer -� � �-����"�>—+�-����"�fplodel
<br /> �Casing Protection �12 in.above grade
<br /> �At-grade(Environmental Wells and Boring ONLY)
<br /> GROUTING INFORMATION -
<br /> Well grouted �es ;J No
<br /> Grout material ❑Neat cement ❑Bentonite r;Concrete,�High Solids Bentonite �
<br /> from � to � ft. 3 �-��yds �6ags �
<br /> from�to�ft. Q�tt�ra3 �j�CJ. �' bags
<br /> GEOLOGICAL MATERIALS COLOR H MADTERSA OF FROM TO from to ft _,yds. ���—�.bags ,
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> t[971OA.L1 �1,�� '� 0 3 "'. `.. _ feet ...-'�'�''_3 direction �.�✓--)^'�' 'l'al+''-d`.1�` v
<br /> "r"" Well disinfected upon completion es � 'No -,_\,ti,.,_, �,,,yl._��.
<br /> _y� ,��w �� � �PUMP � .
<br /> C� L�7V1LS
<br /> .Not ins�alled Date installed �'J T�'"�J `-�-�
<br /> �►�a �gt 9P1 420 Manufacturer's name_ ��--._.•�`--��-+.w-- �-:"'�°s "�
<br /> k�J L
<br /> Model number HP J��Volts �`7
<br /> � b� �1 G i� 1�Length of drop pipe /`l� ft. Capacity g.p.m.
<br /> Type:' .;Submersible j �L.S.Turbine ❑Reciprocating �J Jet ❑ �
<br /> ABANDONED WELLS
<br /> 3 Does property have any not in use and not sealed well(s) �_]Yes �No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ❑Yes ' No TNu
<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. � SEodola We.I.2 Dcil�ing Co�• i� 4�!�
<br /> Licensee Business Name Lic.or Reg.No.
<br /> _. .
<br /> // /�' �.,'
<br /> th e Representative Signa�ture Date
<br />.., � 1 R)f)�
<br /> LOCAL COPY ��� � ,�[; � NameofDriller
<br /> ej�
<br /> HE-07205-08(Rev.5/02)
<br /> IC 140-0020
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