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� \ <br /> 1 — ' � <br /> � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIC?UE WELL NO. <br /> -�� CountyName WELL AND BORING RECORD / � C <br /> Minnesota Statutes,Chapter 103I r ��,E Q'� � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> y, y, �i <br /> �, GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds �� _ <br /> Longitude degrees minutes seconds �__�Cable Tool i nven ,;Dug <br /> ��Auger ���,Rotary ��Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number U <br /> ��"DRILLING FLUID WELL HYDROFRACTURED? ��i Yes ` � o <br /> Show exact location of well in section grid with"X". Sketch map of well locati��� �$t�r FROM fL TO ft. <br /> Showing property lin '� <br /> roads and buildin s�. USE <br /> N ,��Y� ,,,/// ❑Monitoring ❑Heating/Cooling <br /> �Domestic �,i Environ.Bore Hole� [;Industry/Commercial <br /> -- -- - -- v <br /> J Noncommunity PWS r�Irrigation ,_,'Remedial <br /> - � � � ; ❑Dewateri ❑ <br /> , , , €� ,.�.. ❑Community PWS ng <br /> � --i--- --�------;-- ---`-- ' <br /> ' CASING HOLE DIAM. <br /> ; W � ; ; ; E T Drive Shoe7 �]Yes _--No <br /> � �Q <br /> -- -- -- - -- I . �-- -_ p <br /> ��.Steel ❑Threaded i Welded <br /> '/z Mile 11StiC ❑ ___ <br /> -i- ' : i <br /> ; __'___ _"___ __�__ ___;__ <br /> 1 4,1 CASING DIAMETER WEIGHT <br /> S Z/\ <br /> � in.to ��� ft. ��01 IbsJft. � in.to -��}f - <br /> �1 Mile� b � . _ .___ — . __—_ �� Q� <br /> • - � � - in.to __ft. IbsJft. "7 in.to ��4f. <br /> � PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> ,�, SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make FROM_ ft. TO ft. <br /> � � �� Type St '�f1 �S��.l,___ Diam. ,_ <br /> SIoUGauze______�� ._____Length� .R �t <br /> Set between ft.and it FITfINGS � <br /> STATIC WATER LEVEL <br /> 1� ft. below [�above land surface Date measured 1��ZTV.J <br /> PUMPING LEVEt(below land surface)• ' <br /> ' WELL OWNER'S NAME/COMPANY NAME ZpV ft.after 3 hrs.pumping 18 <br /> g.p.m. <br /> WE L HEAD COMPLETION �.L.t <br /> Well owner's mailing address if diFferent than property owners address indicated above. itless adapter manufacturer R[ilt��.£�P �M��o�d I______ - <br /> � =1 Casing Protection _ '���12 in.above grade <br /> �i At-grade(Environmental Wells and Boring ONLY) � <br /> GROUTING WFORMATION � <br /> Well grouted �Yes ❑No � � . <br /> Grout material . i_;Neat cement [,i Bentonite �;;Concrete�High Solids Bentonite <br /> from O to_�p fL � [ !yds. �bags <br /> from � to �p3 ft. ���81 ��� �]bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to tt. <br /> MATERIAL ❑yds. i��bags <br /> � NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � <br /> F �=� feet ��. directi6n r ��� type <br /> Well disinfected upon completion � Yes ❑No <br /> PUMP <br /> ��Not installed Date installed Z"'7�i <br /> Manufacturer's name <br /> � Model number _ HP�__Volts i <br /> Length of drop pipe 1�7 ft. Capacity g.p.m. <br />� Type:�Submersible ��LS.Turbine []Reciprocating ❑Jet ❑ <br /> ABA ONED WELLS <br /> 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? ! i Yes No TN# <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 irue to the best of my knowledge. <br /> Use a second sheet,il needed �+ <br /> � REMARKS,ELEVATION,SOURCE OF DATA,etc. � .7tc�dola Well 1�iI lia� Co,• iQC• �/1/{, <br /> Licensee Business Name � Lic.o eg.No. <br /> 7 <br /> x-��w <br /> ho resentative Signatur� Date <br /> C�C MDOL'+� iZ�Z9—�3 <br /> LOCAL COPY � NameofDriller <br /> �� 59 .�1 <br /> HE-01205-08(Rev.5/02) <br /> � IC 140-0020 <br />