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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH 1 MINNESOTA UNIQUE WELL <br /> AND BORING NO <br /> County Name WELL AND BARING RECORD {� <br /> Minnesota StgtUtes,Chapter 1031 ,7 6-L 610 ' - <br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed)- DATE WORK COMPLETED <br /> orate 117 23 7 ` 'A 'A 'A 135 ft' 24548 <br /> GPS Latitude degrees minutes ;seconds DRILLING METHOD <br /> LOCATION: ❑Cable Tool ❑_Driven D Dug <br /> Longitude degrees minutes seconds <br /> ❑Auger l ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ <br /> 4755 llartit Shore Deo Gram DRILLING FLUID pDJIOFRACTURED ]Yes o <br /> Show exact location of welVboring in section grid ith"X." Sketch ap of welVboring location. ft.To ft. <br /> Showing property lines, <br /> N roa ,buildings,and direction. USE omestic ❑'Monitorin <br /> g ❑Heating/Cooling <br /> ---f- I- --- -------- ❑Noncommunity PWS ❑Environ.Bore Hole <br /> ❑Industry/Commercial .,"., <br /> . . `. <br /> ❑Community PWS ❑Irrigation ❑Remedial ;' <br /> r <br /> -- - -❑.Elevator ❑Dewatering ❑ a <br /> W E 4 <br /> i f T r CA ^". .,, Drive Shoe? ❑Yes [ o HOLE DIAM Y <br /> inSteel ❑Threaded ❑Welded. <br /> %Mile .E <br /> d� <br /> [Mastic 0 <br /> iCASING <br /> S tt` Diameter Weight Specifications <br /> I1 Mile _I in.to�ft. ri_Ibs./ft. 1 _ <br /> ---- in.to <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. n.to <br /> in.to ft. lbs/ft. in.to ft. <br /> litarillen HOLE <br /> Property owner's mailing address if different than well location address indicrted above. SCREEN <br /> Make From ft.-To ft. <br /> Type a__ Diam. 311 <br /> SIot/Gauze . Length <br /> Set between and ft- FITTINGS__4"301)._STATIC WATER <br /> Measured from '•_ <br /> ft.(slow❑Above land surface Date measured 1145111438 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ` ' - <br /> ts ft.after j hrs.pumping 108 q.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above.` WELLHEAD COMPLETION <br /> ?Clew/adapter manufacturer I <br /> Casing Protection. [2 in.above grade <br /> ❑At-grade(Environmen 0l Fand Boring ONLY) <br /> GROUTING INFORMATIDPI <br /> Well groutedes ❑No <br /> Grout materials ❑Neat cement[ entonite ❑,Concrete❑Other <br /> f_To <br /> ft. ..______,,,j___ ❑Yds. f <br /> agsmags <br /> HARDNESS OF From To I a,,ft. ' 0 Bags, <br /> GEOLOGICAL MATERIALS COLOR FROM TO —y <br /> MATERIAL From s To i ft <br /> gs <br /> a. NEAREST KNOWN SOURCE OF CONTAMINATION t <br /> "11111011100111 area alret 0 0 (00 <br /> feet direction _ <br /> 11,46. iiiiiir Well disinfected upon completion? es ❑No ` <br /> ebKr ow sett amp Asro PUMP <br /> ,: ❑Not installed Date installed 3, .3"- <br /> Manufacturer's name +"+ 1 <br /> .Model Number HP Volts <br /> '. Length of drop pipe #05 ft. Capacity g.p.m. <br /> Type:[dubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes <br /> VARIANCE ! <br /> Was a variance granted from the MDH for this well? ❑Yes ^[ lo TN# <br /> WELL CONTRACTOR CERTIFICATION r <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.Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> ailleStedellaVal Thant* . lee* <br /> Licensee Business Name Lic.or Reg.No. <br /> 3 a <br /> C r . . n,:cr, gna: Certified Rep.No. Date <br /> LOCAL COPY e+e <br /> 1 760610 Name of Driller <br /> IC 140-0020 HE-01205-11(Rev.3/07) <br />