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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 7 a 5 9 <br /> Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> 118 23 35 <br /> GPS197 R. 6-17-04 <br /> Latitude degrees minutes seconds DRILLING METHOD <br /> LOCATION: ❑Cable Tool ❑ ri <br /> Longitude degrees minutes seconds ven ❑Dug <br /> ❑Auger Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number <br /> 1005 Old lam Ti Rd 55391 DRILLING FLUID . WELL HYDROFRACTURED? ❑Yes,'No <br /> Show exact location of well In section grid with"X". Sketch <br /> )Sketch map of well owino pr ,,tion. FROM ft.TO ft. <br /> N :..j ICL L c v't L 'c�h ideljngs USE <br /> ❑MonitoringHeating/Cooling <br /> • ❑ <br /> w Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> ; Noncommunity PWS ❑Irrigation ❑Remedial <br /> ---i-----'--- ------h--• - ❑'Community PWS ❑Dewatering ❑ <br /> w ; ,E v' CASING <br /> Drive Shoe? ❑YesNo HOLE DIAM. <br /> r ------i--• ❑Steel ❑Threaded Ided <br /> % - ,blas ❑ <br /> Mile ` <br /> ,h tic <br /> - , --t----t— -. 1 t:rCASING DIAMETER WEIGHT <br /> S „ <br /> 4 <br /> 189 <br /> I---1 Mile---Iin.to ft. + Ibs./ft.: in.to <br /> in.to It. lbs./ft. in.to Z7ift. <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> in.to ft. IbsJft. in.to ft. <br /> Standmee OvoistrectionSCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make JohnsonFROM TO ft. <br /> 420 It Rice St Type injitaidil iit Diam. <br /> MN 55+J 9 Slot/Gauzei Length <br /> •9i Set between Iftnf ft.and ft., FITTINGS 2,4~ grAftra. <br /> STATIC WATER LEVEL '�,., <br /> 85 <br /> ft' below ❑above land surface Date measured +'"-"'O4 <br /> (belowPUMPING LEVEL land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> ft.after hrs.pumping q.p.m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer t v 4 4 r Model <br /> Casing Protection [(2 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes ❑No <br /> Grout material Neat cement El Bentonite ❑Concreted/ Iigh Solids Bentonite <br /> from to_ ft. ❑yds.rags <br /> from_to_! fts. ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. <br /> MATERIAL ❑yds. ❑bags: <br /> NEAREST KNOWN SOURCE OF CONTAMINA ION <br /> 6. <br /> feet direction ..7 R .,,I' <br /> Well disinfected upon completion yes ❑No <br /> PUMP <br /> Soadicocke brown soft 6 10 ❑Not installed Date Installed ! - Ips GM <br /> clay smy sati g Manufacturers name <br /> Model number 111.111 HP It 1 Volts r <br /> mend way soft 60 No Length of drop pipe {6 ft. Capacity <br /> g.p.m. <br /> Type:; ,, ubmersibte ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ • <br /> CillyittititilSSW to no ABA, ONED WELLS <br /> Does property have any net In use and not sealed well(s) p Yes 0000 <br /> garret -colored1 Imo <br /> 1' VARIANCE �1/ <br /> Was a variance granted from the MDH for this well? 0 Yes Flo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> 'This well was drilled under my supervision and•i0.accordance with`Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to th'e.bestof my knowledge. <br /> Use a second sheet,if needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Dan St 040441i Ocilliag I, Itloo 27172 <br /> Licensee Business > Lic.or:eg.No. <br /> .' - <br /> A7../..., ..,,, ..,,,, <br /> A •Piz==rep'j eri alive Slgnatu ifir - 1.r— Date <br /> LOCAL COPY 705912 Name of Driller <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />