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I <br /> 4F.LL L,('.CATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name ipin WELL RECORD 536157 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> Cron° 117 23 09 ,, v. v. 1'06' 12-16-93 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> 10°0 Old Crystal Bay Road Orono, Mn. ❑ Auger ❑*otary ❑ Jetted <br /> SatitIn of well in section grid with"X". <br /> chavrerntfir <br /> 4. <br /> Z Sketch map of well location. ❑ <br /> Well <br /> Showing property lines, <br /> l roads and buildings. DRILLING FLUID <br /> j N <br /> i <br /> --�- -1--1- Qiri WC 41- $t'IItUri1te <br /> t i .USE Domestic ❑ Monitoring ❑ Heating/Cooling <br /> ❑ Industry/Commercial <br /> yy i ; I E Irrigation ❑ Public <br /> ._1__-1- -- ^-- T D 0 Test Well 0 Dewatering O Remedial <br /> hmi. <br /> V CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --t- - - ---r- <br /> ❑ teel ❑Xhreaded 0 Welded <br /> /mile Q ❑ Plastic ❑ <br /> Q� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNERS NAME4 <br /> n.to 104. lbs./ft. <br /> lake 'I.,ra. .lCir'Ttes _firs.to :A. <br /> in.to ft. lbs./ft. �_/jn,to -ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in./ to ft. <br /> Bob Melared SCREEN OPEN HOLE <br /> 1212 Wayazata Blvd. t-;,,�tMake JO;t,n,,�on from ft.to ft. <br /> Way`za tc1� i�l.Cf539 Type '�s'32.I1� 5<i Step" Diam. 4" <br /> Slot/Gauze . Length <br /> Set between 1€'We <br /> ft.and 108 ft. FITTINGS: 4' <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 40 t <br /> MATERIAL ft. ❑flow El above land surface Date measured 12-16-4 <br /> t PUMPING LEVEL(below land surface) <br /> Clay 90' ft. after hrs.pumping g.p.m. <br /> COMPLETIONWELL HEAD <br /> Sand 90' 1 U8 f❑fi I ss adapter manufacturer <br /> X17 tp4tiltstrModel <br /> C Casing Protection ❑I2 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? ❑.yes ❑ No <br /> Grout Material ❑ Neat cement 0 Bentonite <br /> from to .."i- ft. .- ❑ yds. LI .bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATIONy-{rr <br /> 7c- feet ti�'0�I%, direction �. t4 type <br /> Well disinfected upon completion? ❑ Yes 0 No <br /> PUMP <br /> ❑ Not installed Date installed 2-24-94 <br /> 4 <br /> Manufacturer's name ti/i in F C ari <br /> Model number HP i Volts 23(1 <br /> Length of drop pipe 4- ft. Capacity 16 g.p.m. <br /> Pressure Tank Capacity 1' t..t Wp''.3 vi.,te <br /> Type: ❑,submersible C L.S.Turbine 0 Reciprocating 0 Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑)tio <br /> WELL CONTRACTOR CERTIFICATION ,J` <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 /> 1lii S1 1 ff2.. WELL DRL J a NG U ., INC. i.717; <br /> Use a second sheet,if needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name or Reg.No. <br /> -77--- <br /> __-- -- 1./-16-9 <br /> •r o ed Rep, -nt• 'e ig azure Date <br /> F.P. McMahon 12-10-92 <br /> Name of Driller Date <br /> LOCAL COPY 536157 HE-01205-04(Rev.5/92) <br />