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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL RECORD � � � ��� �
� Minnesota Statutes Chapter f031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion
n.
Oma�o 118N 23W 29 �,.I��. ��.
Numerical Street Address or Fire Number and City ot Well Location DRILLING METHOD
34fl5 Coun R�oac� 6 r��3�� C Cable Tool Driven �� Dug
❑ Auger � Rotary _ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑ '
Showing property Nnes,
N roads and buildings. DRILLING FLUID
I � '
--r-�- -j -1-
i �
i � � � USE �
--�- -',- �- �- � Domestic 7 Moniroring C Heating/Cooling
W � ' � ' E Irrigation � Public G Industry/Commercial
i
_1_ _1_ __ __ ���._I Test Well = Dewatering '.7
1 � '
' f�mi. CASING Drive$hoe? C Yes � No HOLE DIAM.
--�- �- ; -r- I � C Threaded L 1 Welded
� ' 1
�—I+nile'� F��� � S •"r tt��... � � Plastic �' glitP
' CASING4DIAMETEF ��� ' WEIGHT $ 170 �
PROPERTY OWNER'S NAME in.to ft. Ibs./ft. in.to ft.
� in.to ft. Ibs./ft. _in.to fl.
Mailing address if ditterent than property address indicated above. in.to ft. Ibs./ft. in.to ft.
SCREEN OPEN HOLE
Make Tr3VYY'1 from ft.to ft.
T
7ype k1�"•�� Diam. n
SIOUGauze �5 Lengthl����
Set between ��i tt.and 17n ft. FITTINGS:
STATIC WATER LEVEL
FORMATION LOG COLOR HARDNESS OF FROM TO '� ft.j}� below ❑ above land surface Date measured
FORMATION � �
PUMPING LEVEL(below land surface)
�1 b�+ Q � ft. after hrs.pumping z�g.p.m.
WELL HEAD COMPLETION
`'�� �m1 i� 2 '� �Pitless adapter manufadurer ttu..,.A.. Model -r
�cs
i7'Casing Protection
4t4y b�.te gray 25 $Q GROUTING INFORMATION
� Well grouted? � Yes � No
1 �t $�1� ��, $O �5 Grout Material � Neat cement ❑ Benronite
trom_�to�Q_ri. J yds. L bags
from to ft. ❑ yda ❑ bags
Sh31e & gravel red brvwn 135 157 from to n. o ya5. ❑ bags
NEAREST SOURCE OF POSS�BLE CONTAMINATION
� � (�g�l �(� �7 1,7� feet direction type
N[ell disinfeded upon completion? �Yes ❑ No
PUMP
Not installed Date installed
Manufacturer's name RIZ t'�C
Model number HP 3�4 Volts 23t1
Length of drop pipe �� ft. Capacity �� a.p.m.
Pressure Tank Capacity
Type: �I Submersible ❑ L.S. urbine� ❑ Reciprocating f J Jet ❑
ABANDONED WELLS
Not in use and not sealed well on property? � Yes �No
WELL CONTRACTOR CERTIFICATION
This well was drilled under my jurisdication and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sneet,il needed fi}�sprtte Ts7ts11 T}ri 11 i nrr i�_ _ T�_ 2'Z,2 94
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name --, �'T Lic.or Reg.No.
�e
�'Y.. � ..._� �a���iT��
.+futhonzed Represen a ve S�ganture �te
m o a
LOCAL COPY � � � � � � HE-01205-03(Rev.9/91)
STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED MELL RECORD
1. LOCATiON OF �El� MINNESOTA UNIQUE WELL N0. H81897
i�eave Dtank tf not known)
c°""`Y """` Henne i n
Tornsnip Mame Townshfp Number Range NumOer Section No. Fraction 4. 4ELL �EPTN (cospleted) Oate sealed
N E 4 k of y
Orono 118N s� 23W w' 29 SE NW SE 86 f`• 3/24/93 !
,
Numerical Street Addresz and Lity of Nell Location or Distance from Road 5. �RILL(NG METH00 (1f know�) ;
(nursection 1�Cable tool 4�Reverse 7(]DNven 1�Oug
3405 County Road 6 Long Lake, MN 55356 Ho�,o� aaa �
2[] SQAtr �Bored 11� �
i
SAow eaact locatton of well
3�Rotary 6�Jetted 90 Pow�r Auger
� (in sec N on grid rltA 'X') Sketth map of well louttOn
6. OBSTRUCilONS
� , welt obstructed Q Yes [JC� No
- � - - - - -- -. ODscructtons removed 0 Yes []No If obstructions cannot ee
� �
� removed, contact lIOH I
y - • - - • • -I- . - E Cefore sealing.
: . , T �. �SE
, ' �x ti.�. l�Domestic a0 lbMtoring 80 Neat looD
; ; _ ; : I 2�lrrigation 50 Public 90 [neustry �
I
' ' 1 30 Test Mell 6�Municipal if�Comaercial I
� �--1 SL---r ]QAir Gondltianing 11(] I
2. PRUPERTY ONNER'S NAME Mailtng Address if dlfferent than 8. CAS[N6(S) I
� property address indicateE above 1[�Black CQ Threaded 7[] 1
� i
2[J Galv. 5[]Yelded �
Charl otte Forsythe J[]Plastic 6�Statnless Steel
�
NARDNESS OF (} I
l. FORMATION lOG COLOk FONMIlTION FROM TO 1n. to ft.
if not known, indfcate forma[fon tog from new well or nearby well. in. to /t. �
TO S 0 1� �d C IC Q 2 9• SCREEN ,
�Screened vNl l tros ft. to ft. �
e 1 1 0 2 2 5 ❑ODen Hole from ft. to ft, (<� known) �
— — ,
C�a,Y �u e� ray 2 5 8� 10. STATIC WATER LEYEL �
Gravel & sand ul ti 80 g6 �� f`• � De1oy ❑'°°"' 3 24 93
lend surface Oate Meesured � �
11. WELLNEAD COMPLETION �
1�]Pttless Adaptar �Founa Buried �
2[]Basement offset '� �
30 Well Pit �
16. REMARKS, ELE4ATION, SOURCE OF OATA - CASIN6S REMOVED, CASIHGS PERFORATED, ETC.
12. GROUTING INFONlNTION i
� 1�Neat Cement �Bentonit� � i
IFormation log taken from new wel l dril led Grout material 7 baqs ,rom 0 �,86 ft. ��. ,as�
I 10/5/92 - unique well #480299 _ _ ;
---�
13. NEAREST SOURCES OF CONTAMINATION
_ feet directlon �ype
Well dlsinfect�d befon sealingt � Yes
14. PUM� �Remnved �Not Prasent !
Type: l� Submtrslbte �L.S. TurOine �Reciprocating ;
2[J Jet �Centrtfug�l 6� I
�
15. ElIISTING MELLS (Ple�s� sk�tcA loe�ttons at abanConed and �
activ� walls tn rewrks sectton or on oack.) I
Othar unused w�ll(s) on prop�rtyT �Yes �No
Abandoned: []Perm�nent �Temporary �Not sealed I
17. NATER HELL CONTRACTORS CERTIFICATION
This Nell was sealed under my jurisdtction ana this repor[ I
is true to the best of my knowledge and beltef.
Stevens Well Drilling Co. 27194
"�C�6��0��11sig�iwav 12 We`s,�`�z` N°. �
Aaa�e�s Ma 1 e Pla 'n MN 55359 �
sty�ea i .c �,,. . �-�._. o.ce 3 30 93
��ul Swearingen n,t. 3 30 93
ifIC1AL ABANppNEO YEIL RECORO (lf�y b� used for iroDerty Transier) Nane o1 Dr111��
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