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. , � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> � co��ri Name WELL AND BORING RECORD + <br /> �i![i2 in Minnesota Statutes,Chapter 1037 �� ���� <br /> �� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> t)ca� 12 i 23 07 �, ,, ,, " <br /> GPS DRIL I METHOD <br /> LOCATION: Latitude degrees minutes seconds . _ . <br /> Longitude degrees minutes seconds �Cable Tool r�Driven .�Dug � <br /> — ❑Auger �iotary _Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � <br /> �[} N f,'"�� �► � gQ� DRILLING FLUID WELL HYDROFRACTURED? n Yes . o <br /> J <br /> Show exact location of well in section grid with"X". _,�� Sketch map of we!I location. ���r FROM ft.TO � ft. <br /> � r� Showing property lines, — <br /> � N � !f 9 Noncommunity PWS �Manitorin � <br /> # roads and buildin s USE <br /> ., �/ g ❑Heating/Cooling <br /> �-- � � � � j�.Domestic ,Environ.Bore Hole ❑Industry/Commercial '� <br /> t ���"�'—""""—^-- f] Irrigation ❑Remedial <br /> �< ; I ; ; �( �]Dewatering !L� <br /> � .I Community PWS : <br /> � � -� � �� `-� CASING HOLE DIAM. �� <br /> '� w ; ; ; ; e�- � Drive Shoe? [j]Yes�o <br /> � ' ' ' ' I I�l'Steel ��Threaded � n Ided �` <br /> � --�----�--- --F-- <br /> � '/Mile �Plastic �� ❑ <br /> ; ; ; ; 1 � -- - <br /> : --------------�-- ---.-- <br /> CASING DIAMETER WEIGHT � <br /> � � S � � � <br /> ,�P � in.to 11� ft. Z*� Ibs./ft. �+ in.ro� ft. <br /> �--i M�ie� {'' � ��'�r Q <br /> - - � ""� in.to it. Ibs./ft. �in.�`✓� ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./it. in.to ft. - <br /> � rfll S9 SCREEN OPEN HOLE <br /> s Property owner's mailing address if different than well location address indicated above. Make__�(y�'[j![AR__ FROM ft. TO ft. <br /> Type et�e{wt�rsae st� Diam. <br /> � � � SlotlGauze •�li� Length �___,� ���__ <br /> Set between ft.and it. FITTINGS <br /> STATIC WAT EL <br /> OU tt�' below �J above land surface Date measured TZ�"t�! <br /> PUMPING LEVEL(bel land surface) <br /> WELL OWNER'S NAME/COMPANY NAME �H �,^ <br /> " �I1 ft.after 2 hrs.pumping '�iV g.p.m. <br /> WELL HEAD COMPLETION 1 <br /> Well owner's mailing address if different than properry owners address indicated above. ��i�less adapter manufacturer � ;,)�'�3 T w ;,,t��+��v_r�Model_ <br /> ��Casing Protection `�12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted 't Yes ❑No <br /> Grout material �Neat cement [�Bentonite �:Concrete�High Solids Bentonite <br /> from�to�ft. �_ [j yds. I�.kSags <br /> from�to__��ft ���,��, 7^,bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from ro R. J yds. ���.bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> O �� ��&Cx ��t O � _ feet '�� direction � type _ <br /> Well disin(ected upon completion Yes ❑No <br /> PUMP <br /> �� �� � �0 � �Not installed Date installed J � �-' ���/4 � <br /> w.�,�' r y�,�, ��,t y/� �� Manufacturer's name ��� l�%"� /' - " <br /> lisitiVR i. 1J 9iJ <br /> Model number HP � � Volts <br /> t � �,� 1�' Length ot drop pipe �% ft. Capacity g.p.m. <br /> Type: - Submersible ❑LS.Turbine ❑Reciprocating ,��,�.Jet '�J <br /> V� CO1O� �O� 1VL3 �g� AB DONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes No <br /> VARIANCE <br /> f Was a variance granted from the MDH for this well? jJ Yes ' o 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 true to the best of my knowledge. <br /> Use a second sheet,il needed <br /> - REMARKS,ELEVATION,SOURCE OF DATA,eta �, �'�, I� s IIIC• 27�� <br /> Licensee Business Name Lic. eg.No. <br /> / <br /> ..1 ^ <br /> �- �l- c:* <br /> or' e at e Sign ure � Date - <br /> �2C�[ MOOt@ �1�`�i <br /> 7 ���� � Name of Driller <br /> LOCAL COPY <br /> HE-01205-08(Rev.S/02) � <br /> ' IC 140-0020 <br />