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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> CountyName �FI� WELL AND BORING RECORD 615 5 61 <br /> Minnesota Statutes Chapter103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � Date Work Completed <br /> fl. <br /> flRa�o i 1� �3 c�s ,. �,. �,. z a� • <br /> House Number,Street Name,City,and Zip Code of Well�ocation or Fire Number DRILLING METHOD <br /> 3498 iVarthshnr� Drive Orona MRI. 553�1 O qubeeTool ❑ Driven ❑ Dug <br /> g �] Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �NO <br /> N W�ter. <br /> , , , , FROM n.to n. <br /> -_ -_- — <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i i i ��Domestic <br /> _�_ _� � i ❑ Community PWS ❑ Industry/Commercial <br /> i i i i ❑ Irrigation ❑ Noncommunit PWS <br /> w E T ❑ Test Well Y ❑ Remedial <br /> i i i i ❑ Dewatering ❑ <br /> i i i i �/zIM_1e CASING Drive Shoe? �1 Yes ❑ No HOLE DIAM. <br /> _i i � i_ � w�,�� � � Steel ❑ Threaded ❑ Welded — <br /> i _ i_ _i_ _i � <br /> ❑ Plastic ❑ <br /> S 1� �/�� <br /> �—,M,�e—� /��jf���'1►���-tll�.f` QK. <br /> CASING DIAMETER WEIGHT <br /> PROPERTYOWNER'SNAME +4 in.to2��3 _ft. � • � IbsJft. ?�n�fo �� <br /> ;{�� A.RI1SO�i in.to ft. Ibs./R. ' �n��i"s�fl. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. ��^�,,�_'�g. <br /> SCREEN � OPEN HOLE <br /> Make from ft.to ft. <br /> Types+S;���.�.� �Z����_Diam. <br /> SIoVGauze Length_ <br /> Set between � ft.and it. FITTINGS: ��'� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME __ �� t ft.� below ❑ above land surface Date measured t����„ y� , <br /> PUMPING LEVEI(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 2�� ft. after 1 hrs.pumping � g.p.m. <br /> WELL HEAD COMPLETION <br /> C�Pitless adapter manufacturer I,PIi 4 i��s r,:n�a r Model , <br /> ❑ Casing Protection �1 12 in.above grade <br /> ❑ At-grade(Emironmental Wells and Borings ONLY) <br /> GROUTING INFOFMASTION <br /> Well grouted? L�+Yes ❑ No � <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement�(7 Bentonite ❑ Concrete �High Solids Bentonite t, <br /> MATERIAL from�__to�_ft. 2� ❑ yds.�7 bags .�` <br /> from_ to ft. ❑ yds. ❑ bags � <br /> ��,r� a n?� � f from to_ ft. ❑ yds. ❑ bags <br /> NEAR�NO�N SOURCE OF CONTAMINATION� /� j�(J <br /> C��_ � � feet ��S ��_� _direction�`��"'c''��������_rype <br /> � Well disinfected upon completion? ❑ Yes ❑ No -^-� � u+4�� <br /> �'' f` rJ' C 1 fPUMP <br /> ❑ Not installed Date installed Z 1—24—9 8 <br /> r'' t �Manufacturer'sname +��C� Jacket <br /> Model number �1�7��r3 HP 3 4 vai�s 2 3 0 <br /> � <br /> k Q � �Length of drop pipe �� ft. Capacity �� g.p.m. <br /> Type: �ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ � <br /> ABANDONED WELLS y <br /> Does property have any not in use and not sealed well(s)? ❑ Yes 'lJ No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes Oxlo � <br /> _ WELL CONTRACTOR CERTIFICATION j <br /> 4 <br /> Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. � <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. 7he information contained in this report is true to the best of my knowledge. <br /> DO1V ST�bCL�1 ��dELL DRIL.LING INC. �7172 <br /> License Business N me -� Lic.or Reg�N�.�� <br /> ,.�.—t;,s .r' 1 <br /> uthorized Repres' ve Signature Date <br /> Fred Lei.�y IO-29-98 <br /> _—__ -_— <br /> Name ol Driller Date <br /> LOCAL COPY � ,��� S�, HE-01205-06(Rev.9/97) <br />