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MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> ., ,:�a�ne '-� WELL AND BORING RECORD 5 910 8 4 <br /> , ti�3,`::i�'f1177 Minnesota Statures Chapter 1031 <br /> �. <br /> Township Name Township No. Range No. Section No. Fraction WEL�DEPTH(completed) Date Work Completed <br /> n <br /> �',_�nc� 117 2� l�� ,. �,. �,. �� ' 1-29-�8 <br />�'� House Number,Street Name,City,and Zip Code of Well Locauon or Flre Number DRILLING METHOD <br /> j� � J Northshcre D��.�7� Ur�.��10� � ;,����� � n CableTool ❑ Driven ❑ Dug <br /> - ❑ Auger �7 Rotary O Jetted <br /> Show exact location of well in sedion grid with"X". Sketch map of well location. ❑ __ <br /> Showing property lines, -�— <br /> N ryI roads and buildings. DRILLING FLUID $��t0n�.t� <br /> � <br /> i i i � <br /> _�♦>.. -i -i- -i- -�- � <br /> � ,.!/�� USE � ❑ Monitoring ❑ Heatinq/Cooling <br /> � W G Domestic <br /> _i_ _�_ _a_ _i_ O j( ❑ Community PWS ❑ Industry/Commercial �� <br />+��:�` i i i i ❑ Irrigation ❑ Noncommunit PWS <br /> w E � ❑ Test Well Y ❑ Remedial <br /> , � i i � T � - - ❑ Dewatering � _ <br /> .r <br /> � � � i ,/zIM1e CASING Drive Shoe? ❑ Yes XI No HOLE DIAM. , <br /> _i i _L_ _i_ � h ❑ Steel ❑ Threaded ❑ Welded . <br /> � _�- � � � �] Plastic ❑ _ __ <br /> S Q <br /> �-1Mile-� � <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �i in.ro I� n. SDR—2 1 Ibs./ft. � 1id tbf �'K. <br /> Betty Vogt - <br /> in.to ft. Ibs./fl. �_��t�.�� <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. ____ Ibs./fl. in.to ft. <br /> SCFEEN_ OPEN HOLE <br /> Make�� n������dn from ft.to fl. <br /> Type Stain�ess Steel Diam. L�� <br /> SIoVGauze '3/i fl Length �j � <br /> Set between �� tt.and__��_tt. FITTINGS: � t <br /> STATIC WATER LEVEL <br /> s <br /> WELL OWNER'S NAME �^� ft.�below ❑ above land surtace Date measured �"29"� � <br /> PUM'p7 ING LEVEL(below land surface) 3 <br /> Well owner's mailing address if differeM than property owner's address indicated above. ` � __ft. afler � hrs.pumping J U g.p.m. <br /> - WELL HEAD COMPLETION <br /> �1 Pitlessadaptermanufacturer W�l�..���ldc3��� Model <br /> ❑ Casing Protection �,�] 72 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMvAT��ION <br /> Well grouted?�!J Yes ❑ No <br /> HARDNESS OF Grout Material f7 Neat cement Benton te ❑ Concrete Hi h Solids Ben�tqnite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � � �0, 9 X <br /> from � to � ft. � ❑ yds"fl bags <br /> from_ to ft. ❑ yds. ❑ bags <br /> C�.ci Sand Ca�cl @�. BZc�C�C CJ Q � � from to ft. ❑ yds. ❑ bags <br /> NEARES�KN N SOURCE OF CONcTA�MINATION ,/ <br /> i�- � feet J UC.� t iY direction � t i � <br /> Cla Gr�vel an S 3G 7U � �a,�-ryPe <br /> . Well disinfected upon completion. ❑ Yes ❑ Na f� ^� �� � <br /> .c7t��� �.�cin �J �Ei V 2 PUMP <br /> ❑ Not installed Date installed L-'t��9� <br /> Manutacturer'sname �EC� uc3C}�E� 1 <br /> Model number �s" ' HP 1 Volts l��� <br /> Length of drop pipe tt. Capaciry �� g.p,m. <br />��-�- Pressure Tank Capacity. PC��.3 <br /> Type: t� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes L�IfJo <br /> _` , VARIANCE <br /> Was a variance granted from the MDH for this well? �Yes ❑ 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,eta The information contained in this report is true to the best of my knowledge. <br /> DC)N StUDULA WELL DRTLLING CO. , ,TNC. , ` <br /> Y _�' i� �i._,� w <br /> f Licensee Business Name Lic.or Reg.No <br /> ��I r.J \., 'I-' . <br /> „ � 3 ��. ��1�I���c��v <br /> uthonzed Represent ve Signature Date — _ �'y <br /> �;�e Y �r�:: :..: _ F"rea Leib <br /> Y 3-1 ts-98 <br /> Name ol Driller Date <br /> LOCAL COPY 5 910 8 4 „E-0,2a�5,Re�.,,�5> <br />