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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCA11'ON MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD 6 ... <br /> Minnesota Statutes,chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction(sm.--►lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> IA /a la ft. <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger ❑Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with X." Sketch map of well/boring location. ;-,rt t 0 - From ft.To ft. <br /> Showing property lines, • <br /> N roads,buildings,and direction. USE M Domestic ❑Monitoring ❑Heating/Cooling <br /> 1 I — <br /> . ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ji ❑Community PWS ❑Dewatering E Remedial <br /> 1- + ---- - ❑Elevator ❑ <br /> w E T CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM. <br /> -1---T-"-f' ❑Steel ❑Threaded ❑Welded <br /> '/z Mile <br /> ❑Plastic ❑ <br /> I .-... CASING <br /> s <br /> i i 1 Diameter Weight Specifications <br /> 1 Mile ,' in.To ft. lbs./ft. in.To ft. <br /> I �„ <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To ft. <br /> ore in.To ft. lbs./ft. in.To ft. <br /> )` OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN ,?' --' <br /> Make . O h C:S O C? From ft. To ft. <br /> Type stainless Diam. <br /> Y <br /> Slot/Gauze •1 0 Length <br /> Set between 1 7 7 ft.and 1 8 5 ft. FITTINGS <br /> STATIC WATER LEVEL ft. ❑Below ❑Above land surface <br /> Date measured a / _ Dry hole ❑Yes ❑No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after 3 hrs.pumping 0 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> ❑':Pitless/adapter manufacturer -1,1)n 1.t or Model •'1 1 1 d O,., <br /> ❑Casing protection ❑12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material Cut t 1 n rY 9rom 177 To :-''9 ft. ❑Yds. ❑Bags <br /> Material 1te f t O n i tFfam 5 n To ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Well is feet direction from___ type <br /> Well disinfected upon completion? ❑Yes ❑No <br /> r, <br /> PUMP <br /> lay -,re, <br /> ❑Not installed Date installed <br /> ' r o w n 3 5 4 Manufacturer's name Shafer <br /> Model Number HP / '' Volts • <br /> -Si . ,' --;, '4 1 3 2, 1 3 1 2 6 ft. Capacity I ,� Gray 1" Length of drop pipe �- g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> i-i ne Sand ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes ❑No <br /> 7 n n 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. <br /> ' ' ! " l 11n8 Co Inc <br /> Licensee Business Name Lic.or Reg.No. <br /> , ., /5,170 il / 1 7 i '''':' <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 0 ` * I - ,i <br /> -` Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />