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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �o���YName WELL AND BORING RECORD 6 5 5 0 2 8 <br /> Henne in Minnesota Statutes Chapter f03/ <br /> Township Name - Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Orono 117 23 OT ,. ,. ,. 247 IO-23-00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 112 5 N Arm Dr Orono 5 5 3b4 ❑ Cable Tool ❑ Driven [] Dug � <br /> . ❑ Auger ti[yl4otary ❑ Jened !:. <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ /� � <br /> ----__ --... � <br /> Showing property lines, S <br /> �and buildings. DRILLING FLUID WELL HYDROFFACTURED? ❑YES�O <br /> N �cI t..�...�,Y�. � <br /> i i i i uick� el FROM fl.to ft. - <br /> _i_ _i_ _i' _i_ <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i �omestic ❑ Communit PWS <br /> -�- --�- -�- -�- ❑ Irrigation Y �J Industry/Commercial <br /> i i i i r -^� ❑ Noncommunity PWS ❑ Remedial <br /> w i l e T �� ! ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> i , i i '/zIM e +�1` CASING �Drive Shoe? ❑ Yes 6 No HOLE DIAM. <br /> _i i i _�_ � .._,,,_,�„�„�„_ ❑ Steel ❑ Threaded _ �� ❑ Welded <br /> � � � � �.plastic ❑ <br /> s <br /> �1 Mila� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �in.to �A_ft. __ BfI t"��_ Ibs./fl. L���_� <br /> ; Valerie Fetersen —_ ��.to-----h __ _ �bs�h. ���.�0��47 <br /> Property owner's mailing address if different than well location address indicated above. _.__ in.to ft. ___ Ibs./fl. in.to__tt. <br /> SCREEN��� OPEN HOLE <br /> Make uv�l�t3�7i1 irom ft.to ft. <br /> .... ----------. .. -. <br /> Type S t A�i!� 14 t;�_t_���_Diam. __ <br /> SbUGauze'.v1(1 Length�l_ ,� � f _ <br /> Set between _ ft.and it. FITTINGS: <br /> -_-�---- �- <br /> STATIC WATER LEVEL t <br /> WELL OWNER'S NAME 8� ft.�.below ❑ above land surface Date measured 10�'23 0 <br /> /C <br /> PUMQPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicatetl above. Z C7� _ ft, after 2 hrs.pumping_ 2�_g.p.m. <br /> WELL HEAD COMPLETION <br /> �Pitless adapter manufacturer vjf��evs t o r Model <br /> l7 Casing Protection �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 Grout Materia� !] Neat cement ❑ Bentonite f 1 Concrete �Fligh Solids Bentonite <br /> MATERIAL from to �Q ft. ❑ yds� bags <br /> �-_ �V. ._��i� <br /> from to ft bags <br /> f „J from� _ to�ft. �8 �r8 ���.� bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type f. <br /> a --- <br /> Well disinfected upon completion? �Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed <br /> Manufacturer's name <br /> ° Model number _ HP� Volts_9 9 A <br /> iti7V- <br /> Length of drop pipe 1[�S _ ft. Capaciry ________g.p.m. <br /> Type:�ubmersibie G LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �No <br /> VARIANCE <br /> Was a variance granted from ihe MDH for this well? ❑ Yes �o TN# <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. y <br /> .� �._y L�b�� ine JJi A1�1 Li. sg.iVo.li�<� L/ 7� �: <br /> < r : <br /> " .._.....« ,,� -� �. <br /> : �,;;�-. _ ' 11–I-00 � <br /> � Authorized Representahve Signature � � � Date <br /> Duane Mathevs IQ-23-00 <br /> 6 5 5 0 2 8 Name oi Driller Date <br /> LOCAL COPY HE-01205-07(Rev.?J99) <br />