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_ • �. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> ': CountyName WELL AND BORING RECORD <br /> Minnesota Statutes, Chapter 1037 �� ��� � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �� �� �� 161 N i-ZS-05 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven -Dug <br /> ��Auger �Rotary [�Jetted <br /> House Number,SUeet Name,Cily,and Zip Code of Well Location or Fire Number � <br /> DRILLING FLUID WELL HYDROFRACTURED? ��Yes No <br /> Show exacl loca�ion of well in section grid with"X". ,_ ketch map o�we!I location. �ter FROM R.TO fl. <br /> Showing prop@(ty lines, -- <br /> N roads a 'tTuildings USE — ; <br /> w J Domestic y ��En9ironl Bore Hole �'Heating/Cooling � <br /> Industry/Commercial i�� <br /> �Noncommunit PWS Irri ation .Remedial <br /> �' ; ; ; ; ❑Community PWS ['Dewatering I . <br /> _ <br /> CASING HOLE DIAM. <br /> ___� � . <br /> ; � I I I f <br /> w ; ; ; ; e T Drive Shoe? �Yes �No - <br /> __;___ _;___ __�__ __,__ I �"'"'�''� � �, ❑Steel ' ,Threaded �Welded , <br /> , '/z Mile 18SIiC _ _ <br /> -,___ "„" ' "' ;__ � '. <br /> 1 ` CASING DIAMETER WEIGHT <br /> s � �,, 1',� �f p �/� <br /> �iMiie—� ��'�- `_���r' �in.to 253 ft. G��Z IbsJft. C�in.to�tsft. <br /> __ in.to__. __ft. _._.._ Ibs./h. .�in.toi V1 ft. <br /> �� PROPERTY OWNER'S NAME/COMPANY NAME in.to__ ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE . <br /> fi <br /> Proper!y owner's mailing address if ditterent than well location address indicated above. Make FROM ft. TO ft. <br /> � � $W� Type �� n �.� g Diam.��/���� <br /> SIoUGauze_ _�OlV Length +'F T `'� <br /> Set between�.��_ft.and 162 ft FITTINGS��][�~ <br /> STATIC WATER LEVEL <br />�-�- 'Q tt.� below �!above land surface Date measured �'G7�'l7S <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME <br /> 1�� ft.after _..�;�hrs.pumping � g.p.m. <br /> WELL HEAD COMPLETION - <br /> Well owner's mailing address if different than properry owners address indicated above. �pitless adapter manufacturer._��.��(�,,,j' Model _ <br /> ' Casing Protection �2 in.above grade <br /> ❑At-grade(Environmemal Wells and Boring ONLY) - <br /> GROUTING INFORMATION <br /> Well grouted �!Yes ��.,_]No <br /> Grout material _�Neat cement �j Bentonite ❑Concrete �High Solids Bentonite <br />� from�to__�__,ft. � ' �yds �6ags <br /> from�to�__ft. j��i__�,�, ;]bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. <br /> MATERIAL ❑yds. �bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � ,_ <br /> ; ,/�_J feet �� direction �,,,,.�_1_-� �. t...��"'"'t" rype • <br /> �� Well disinfected upon completion Yes ❑No ,..� .,_, . �j—.,.,..�,� d` j-��,*��- ` <br /> PUMP l� <br /> ��Not installed Date installed <br /> Manufacturer's name �7CLZW��r <br /> Model number HP � Vclts �� <br /> Length of drop pipe ��� ft. Capacity g.p.m. <br /> Type:�� ubmersible ❑LS.Turbine ❑Reciprocating �J Jet r`l <br /> O ABANDONED WELLS _ <br /> a <br /> Does property have any not in use and not sealed well(s) ;]Yes No <br /> � VARIANCE <br /> Was a variance granted from the MDH for this well? [�Yes � No TN# <br /> WELL CONTRACTOR CERTIFICATION <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 /> Use a second sheet,if needed <br /> ��.� REMARKS,ELEVATION,SOURCE OF DATA,etc. �t] JC�OIB Welt Dril����#. IACs 2!1�2 <br /> �Licensee Business Name Lic.or Reg.No. <br /> D�(3"lJ J � <br /> �e epresentative,S� a re Date <br /> (�uck Moare <br /> � � �� q� � Name of Driller <br /> C.E7CAL COPY L� <br /> HE-01205-08(Rev.S/02) <br /> -�- IC 140-0020 <br />