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