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_ , _ � t - <br /> WELL LOCATION MINNESOTA OEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> CountyName WELL AND BORING RECORD 5 9� 5 2 7 ��. <br /> Hennepi n Minnesota Statutes Chapter f03/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orano 117 Z3 7 E NW SW 125 " <br /> �,. �,. 10/2/97 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 13$5 ReSt PO�tit ROdd C7 Cable7ool ❑ Driven ❑ 0�9 <br /> ❑ Auger �7 Rotary ❑ Jetled <br /> Show exact location of well m section grid with"X". Sketch map of well location. ❑ __ <br /> � �� + � Showmg property lines, <br /> �� roads and bwldin s. DRILLING FLUID <br /> " water <br /> � � � � <br /> -,- -,- -,-- -,- '-� <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> , � i , gl Domes6c <br /> _i_ _�_ _�_ _i_ ❑ Irrigation � Community PWS ❑ Industry/Commercial <br /> i i i i �� � `� ❑ Noncommunity PWS ❑ Remedial <br /> w e � � �, ❑ Test Well <br /> i � i � ❑ Dewaterin9 ❑ <br /> � , i r ,�'M� �1 CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i_ _ ,_ _i_ _i_ � � � ❑ Steel ❑ Threaded — ❑ Weltled <br /> i i i i � <br /> �[.I Plastic ❑ <br /> s <br /> �--1 Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME _�__in.to 1 7(1 R 7(l�_Ibs./fg ��.to�tt. <br /> Dav i d Rahn in to ___ft. Ibs/fl in,to��5tt. <br /> Property owner's mailing address if diflerent ihan well Iceation address indicated above. in.to _ft. _ _Ibs./fl. in.to tt. <br /> SCREEN OPEN HOLE <br /> Make_a .�. from ft.to tt. <br /> y'`�`..c'cr__— <br /> Type Diam. M <br /> SIoVGauze��_ _ _Length ',� _ � <br /> Set berween ��_tt.and �e� n. FITrINGS:� p�g}�e� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME _�o ft. �below ❑ above land surface Date measured <br /> - PUMPING LEVEL(below land surface) <br /> Well owner's mailing adtlress if diNerent than property owner's address indicated above. '���ft. afler_ � ____hrs.pumping�_�____(1•� ___g.p.m. <br /> WELL HEAD COMPLETION <br /> � Pitless adapter manufacture Model S..�i�� <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> t GROUTING INFORMATION <br /> Well grouted? �J Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement �eentonite ❑ Concrete ❑ High So�ids Bentonite <br /> MATERtAL <br /> from_�_ro�ft. _�_ O yds.� bags <br /> from to_ ft. C7 yds. ❑ bags <br /> `I'Op SO11 A1dCk St)f� Q '4 r�om �o n. ❑ yds. o bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> sand brown soft 4 11 25 feet N __direction`�e1J2r pii� <br /> Well disinfected upon completion? �Yes ❑ No a i r te s ted <br /> CZC�� blue �ed• 11 IV pUMP '� � � J <br /> �Q.a�� ❑ Not installed Date installed� � <br /> sandy �lay blue "c o nnanutacturer'sname �a�R�1'P __ _ <br /> S�Lt �v �Q� Modelnumber �'�� HP ��oYlts�7 23� <br /> e i ay }J 1{je ��(;� ��'� 2 1 3 Length of drop pipe 6�r� fl. Capacity i e. g p.m. <br /> Pressure 7ank Capacity 2 V 2 _ <br /> gravel b sand je1Zdw me��/ TypeXO Submersible � LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ <br /> �i� ourse 113 135 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes XC7 No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �] No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best ot my know�edge. <br /> RES Well Drilling 27276 <br /> Licensee Business Name Lic.or Reg.No. <br /> /I ..� � -- <br /> ,-="�a^_`-•��J �-- �i _� <br /> Aufhonzed Repres at�ve nature e <br /> � 8obert E. Stodola, Jr. IU/6/97 <br /> Name ol Driller Date <br /> LOCAL COPY 5 915 2 7 HE-01205-05(Rev.1/95) <br />