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� <br /> 1 WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> ' CountyName WELL AND BORING RECORD �- <br /> - HPJ1T2Ej�lI2 Minnesota Statutes Chapter 103I J � 6 4 5 3 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �.�'(.-"'IiC> ��� c�_i �1 St` �.,�,�(;�,i. ��S' n �—��3—y�i <br />� � <br /> r House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> r1�L3 �C3��tL51X�3.'e' �1VE-'`� �'[�Ik:3� �l. Jt..�.5�`J�; ❑ CableTool O Driven ❑ Dug <br /> ❑ Auger Q�Rotary ❑ Jetled <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 <br /> N .FS2Z1�QF11.j�C' � <br /> � � � � <br /> -,- -;- -;- -; <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> � � � i �Domestic ❑ Communi PWS <br /> _i_ _a_ _�_ _i_ -------- ❑ Irrigation � ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> y� I I I I E . ❑ Test Well ❑ Dewatering ❑ <br /> i i i i ,�'M e CASING Drive Shce? ❑ Ves �Q90 HOLE DIAM. <br /> _� i _L_ _i_ � � ;, ��t ❑ Steel ❑ Threaded ❑ Welded <br /> I I I I <br /> Q�Plastic ❑ <br /> S <br /> �-1 Miie—� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �:+' � ���' i•fA �' ��-' <br /> i]s`12L7G��:iI1C1 ���.C3�Y�:i in.to ft. Ibs./tt. in.;o tt. <br /> in.to ft. Ibs./tt. �'-j�,�o_�^�. <br /> Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> �t'J-�f� �1��3-� �� SCREEN_����_ OPEN HOLE <br /> 8��:�CdTll.72fy'�.C?21��1.�.`✓�{f7 Make from ft.to ft. <br /> Type `'�'¢ �� Diam. "n <br /> SIoVGauze �� V � Length � <br /> Set between ��� ft.and t ' tt. FITTINGS: '� ^{ �� � <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME �i'fs' ft. C�below ❑ above land surface Date measured 7—�f5—��j <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. tt. atter hrs.pumping ?i��Y g.p.m. <br /> WELI HEAD COMPLETION �11�E��1,t�,�„�Z, <br /> C�{Pitless adapter manufacturer Model <br /> ❑ Casing Protection C�12 in.above grade <br /> ❑ At-grade(Environmental Welis and Borings ONLY) <br /> & <br /> GROUTING tNFORMATION <br /> Well grouted? C�`Ves ❑ No <br /> GEOLOGICAL'MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement C�Bentonite ❑ Concrete ❑ High Solids eentonite <br /> MATERIAL from i� to �ii ft. ❑ yds. q;bags <br /> '��E�.1C�y; �i..���� '�f�1�.C�1 H {� �cr, from to R. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags � <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> (;]��T ('j�`-L�� ;j j j '�2�� feet direction type <br /> Well disinfected upon completion? ❑1�Ces ❑ No <br /> �71csVE:�. `��cill 1-� u.i S`� PUMP 1`-�J"���1 <br /> ❑ Not installed installed . <br /> �.��! Ure�, � C�"� 'c�y Manufacturersname �'����'E�` ��"' �-'"' rl:i_,st f,.'Ca <br /> � Model number HP -5,� Volts <br /> Length of drop pipe t ft. ,Cap,�ci g.p.m. <br /> Pressure Tank Capacity <br /> :�owrz�r.�;-";�:l.�,� `�=fir�- <br /> Type: C�aSubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Dces property have any not in use and not sealed well(s)? ❑ Yes C�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes O'Itlo <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. .k' <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my know�edge. <br /> � ��i;ix;LF? 4�3� DRILL�P+�G C.�;,, I1�C:.. <br /> Licensee Business Name - Lic.or Reg.No. 4/ �. <br /> �--'- � �{t'i-Q�T <br /> ��:�f�'���� <br /> Authonzed Representafive Signature Date <br /> �:Y�UC'}C MC'�(}L�f? /`^��i—�' <br /> �''' � �a , Name ol Dnller Date <br /> `...i�l.-l�� °-��[�'i` � � � ,�!. �r v <br /> ' HE-07205-05(Rev.1/95) <br />