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� <br /> , � <br /> N�ELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> �o��,Y Name WELL AND BORING RECORD 6 2 3 5 5 2 <br /> H�nne�i n Minnesota Statutes Chapter f03/ <br />- Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 11? 23 OS �. �. ,�. t01 ' " 11-5-98 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD � � <br /> 1550 North Al`11! Drive �L�OIlO♦ . ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �[Rotary ❑ Jetted <br /> Show exact location ot well in section grid wi[h"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> � roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES NO <br /> N ,:.;.. <br /> _i i i �_ � Bentonite FROM ft.to ft. <br /> i_ ___ ___ _i .. <br /> l�• � USE Y ❑ Monitoring ❑ Heating/Cooling . <br /> i � i i �i � fi3 Domestic <br /> _i_ _�_ _�_ �_ � ❑ Community PWS ❑ Industry/Commercial ; <br /> i i � i w ❑ Irrigation ❑ Noncommunit PWS <br /> W E T a. � ❑ Environ.Bore Hole Y ❑ Remedial <br /> � i i � I �,` ❑ Dewatering ❑ <br /> -r -�- -r- -r <br /> i i i i +/ZMia � � CASING Drive Shoe? CJ Yes No HOLE DIAM. <br /> _i i _L_ _i_ � � ❑ Steel ❑ Threaded ❑ Welded <br /> i - i- i i <br /> l �Plastic ❑ <br /> S <br /> �-1 Mile-{ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � 92 SDR.21 <br /> Margaret Peltola '" `° ft. Ibs./ft. in.to n. <br /> in.to ft. Ibs./ft. in.to ft. <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 Johnson from ft.[o ft. <br /> " TyPe Stair►less St..�Q.�Diam. <br /> � ,�h SIoVGauze Length � � <br /> Set between ft.and it. FITTINGS: - <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME '�J rJ� ft. �elow ❑ above land surface Date measured �1'�5�9 <br /> PUMPING LEVEL(below land surface)t 1 <br /> Well owner's mailing address if different than property owner's address indicated above. 8� ft.�afler 1 hrs.pumping 1� g.p.rri. <br /> WELLHEADCOMPLETION �itevater � <br /> l�Pitless adapter manufacturer Model k <br /> ❑ Casing Protection 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLV) <br /> GROUTING INFORMATION <br /> Well grouted? ❑ Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete ❑ High Solids eentonite <br /> MATERIAL from to ft. ❑ yds. ❑ bags <br /> (,`1 a y Ye 1 bc� �J (�� � � from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> �],a�I Grey �' �Q� � fNEARESTKNOWNSOURCEOFCONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? �1 Yes ❑ No <br /> Gravsl Yello S 50' S ' <br /> PUMP <br /> I3-5-98 <br /> C13It Grey S ��• g �� Notinstalled oR��ue �C e <br /> � Manufacturer's namy� � <br /> Sal�a +i+a� �' C37 1 �4 tModel number t) HP voics <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type:4�] Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS y <br /> Dces property have any not in use and not sealed well(s)? ❑ Yes t'9 No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? [1 Yes ❑ No TNM ���� <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed { <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,;e1C The information contained in this report is true to the best of my knowledge. j <br /> D4N ST�DQ�LA WELL DRILLIIdG C0. , INC. i <br /> � <br /> , <br /> _�;_,� � � V � License Business Name Lic.or Reg.No. 2'T;'7 2 <br /> . � 1-I9-98 <br /> - �- <br /> ,; , Authorized Representafive Signature Date <br /> .,�. .. <br /> Frec� Lefby 11-5-98 <br /> Name of Driller Date - <br /> LOCAL COPY 6 2 3 5 5 2 HE_o,2o��,Re�.,�e, <br />