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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH
MINNESOTA UNIQUE WELL NO.
CounryName � � � 5 'g�/ELL AND BORING RECORD 615 212 �
�<311Ii@pgXt Minnesota Statutes Chapter f031
Township Name Township No. Range;N9.� ' S�ct�on�N�..�,�F,r�a n WELL DEPTH(completed) Date Work Completed
OlOAO �.�� �� �3 PI ,��1��. '�J�v. 1�'J� n 1IJ24/9�3
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
13� Crysta� Cir@@�{ GrC�3�0 55� ❑ CableTool ❑ Driven ❑ Dug �
❑ Auger ][Rotary ❑ Jetted
Show exact location of well in section grid with"X". � �Sketch map of well location. ❑
Showing property lines,
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES Q�O
" .._._._�_�_ �L1�CK G�.�
i i i i FROM ft.to ft.
-i- -i- -i- -i- ,_..-=�"�
USE ❑ Monitoring ❑ Heating/Cooling
i i i i � �� /`���� �Domestic ❑ Communit PWS
-�- -�- -�- -�- - -- ❑ Irrigation Y ❑ Industry/Commercial :�
i i i i -���� ❑ Noncommunity PWS ❑ Remedial
w E T �� ❑ Test Well
� i i i ,} ❑ Dewatering ❑
-r -�- -r- -r � ..,
i i i i '/zIM.1e � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
_i i _i_ _i_ � ' � ❑ Steel ❑ Threaded ❑ Welded
� _�- � � € �Plastic ❑
S 1�.._J
�-1 Mile-�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME 4 in.to �.'�8 ft. �U� Ibs./ft. 8 5�j_
in.to
�i,�r�1C� (?a���tl�� in.to ft. Ibs./ft. _in.to ft.
Property owner's mailing address if different than well location address indicated above. in.to ft. _Ibs./ft. in.ro ft. .
G`/E� J fland HOS��S SCREEN OPEN HOLE
15U Soath Nraadxay l�ve. Make a����.'� from tt.to ft.
�a ���i�f � .JJ37�. TYPe ���t. Diam. f�M
Y SIoUGauze �� Length 10�
Set belween ��� ft.and�_ft. FITTINGS:
STATIC WATER LEVEL ,
WELL OWNER'S NAME ,�(�, ft. q�pelow ❑ above land surface Date measured
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. Z�� ft. aRer 3 hrs.pumping �{� g.p.m.
WELL HEAD COMPLETION .t C
l�Pitless adapter manufacturer ��i�i@��*.8lr Model S"�J"'4
❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Wellgrouted? ❑]�s ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ❑](igh So�ids Bentonite
MATERIAL
from_��to�ft. _� ❑ yds. C�bags
� �O from to ft. ❑ yds. ❑ bags
Cl.ay �ri��n ��� from to ft. ❑ yds. ❑ bags
,ya C� NEAREST KNOWN SOURCE OF CONTAMINATION
ciay blue �ea. � ,� ficx�r ar�,t
�2 feet ��g�. direction
sasc� S� �ravel mix
med•� Well disinfected upon completion? C�'es ❑ No .
� s 52 87 PUMP
����� �Y�V ���e ���• �� 1 a� �lot instalied Date installed
•f y
; 1 Manufacturer'sname `l, yc., t� ��t-�
���� � �r�ve� �,q� ��d:� Model number HP � Volts �`�U
; �Dur$G �.�7 �.�✓ Length of drop pipe � L�t/ ft. Capacity �� g.p.m.
Type: �ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS ,
Does property have any not in use and not sealed well(s)? ❑ Yes O�lo .
VARIANCE
Was a variance granted from the MDH for this well? C7 Yes ❑�b
WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge. -
REMARKS,ELEVATION,SOURCE OF DATA,etc.
R}sS �tell Drillin� �72��i
� Licensee Business Name Lic.or Reg.No.
� J
.d-1;-- ,.- ' /'� i� �' /!/L/ '� �
Authorized Representative Signature Dat
Bs�bett �. �todol�►, Jr. i/14/99
Name of Driller Date
LOCAL COPY 615 21�
HE-01205-06(Rev.9/97)