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PORTANT-FlLE WRH Pf10PER M
OWNER COPY
ME01�440 � •••�••
Ty, MATERIAL PRICE AMOl1NT
, ' � WATER PLU3
. 44 Cerrter Street
t-�`' l�.) 11 EXCELSIOR, MN 55331
(612) 4746897
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A'�Ylti � �j-L°O v C. �i C 1�"� DATE _T`�-O` 1 1 `�
�ME , 2248
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L.�Ty PHONE
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Jp9 PHONE OROER T`AKEN BY STn iNG OATE
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TOTAL ,\✓
MATERIAL
TOTAL
LA80R
TAX
� N�u e OATE CO�.�VLE7E0 ��nk`You PAY THIS AMOUNT b sg 4�00
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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 215 6 7
�ienn��in Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Com leted
dre►na 117 23 4 SE SE N�v 1�0 " �%i 3�t�(�
��. ��. ��.
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
1775 D2€r Rtit1 Ttd1I E. OtOtic7 55356 � 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 HYDFiOFRACTURED? ❑YES ❑,p(p
J
N
-�- - �- -� - -�- �1� �.G�i /�<..L�n �a L�r FROM ft.to ft. .�
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USE ❑ Monitoring ❑ Heating/Cooling
� i i i ` fs �..Domestic ❑ Communi PWS
-�- -�- -i- -�- f � ❑ Irrigation Ty ❑ Industry/Commercial
i i i i ! ❑ Noncommunity PWS ❑ Remedial
y�r E � t ❑ Test Well ❑ Dewatering ❑
� � � � T �
i i i -r �/2M1e CASING Drive Shoe? ❑ Yes C�lo HOLE DIAM.
_i_ _ i_ _i_ _i_ � 4 ❑ Steel ❑ Threaded ❑ Welded
i i i i
� 0(Plastic ❑
s
�-1 Mne—�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.to 1�� ft. �'�� Ibs./ft. � in.to ��1
cT g�� �r G111.`Z in.to ft. __ Ibs./ft. _��,to�1��
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
C�5�1 Orchid Lanr� N SCREEN OPENHOLE
1�+3�1� �SrovB� � ��J�j� Make j��:'�tf1� from ft.to ft.
Type c.7 ,. Diam. I`�p
—F::�-L��z'Q�Z�-Efir� f
SIoUGauze �7(Y Length ],�
Setber,�een 13[h.and �.�Q n. FlrrwGs:
STATIC WATER LEVEL
WELL OWNER'S NAME �� ft. O�elow ❑ above land surface Date measured
PUMPING LEVEL(below land surface) !t �
Well owner's mailing address if different than property owner's address indicated above. �1 ft. afler J hrs.pumping �v g.p.m.
WELL HEAD COMPLETION
C�Pitlessadaptermanufacturer '�hite��at�r Model '�'����
❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �.Yes ❑ No
HARDNESS OF Grout Material ❑ Neat cement ❑ eenton e � Concrete ❑�'Ii Solids Bentonite
GEOLOGICAL MATERIALS CO�OR MATERIAL FROM TO �C
from �� to � ft. ❑ yds. LS'bags .�
from to ft. ❑ yds. ❑ bags
�rCs� 5c�il �J'.la�.`K SO�t'. � from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
3r�t1Ct�/ CZ3� UL'C�&It1 ��Cl. j 1 �� feet �'��� direction �E''WFc'.C' j�].��
Well disinfected upon completion? O�es ❑ No
�adlc: & clay j:,iu� �+�d. 16 �3
PUMP
� ❑ Not installed Date installed VP j V�av �
san�i � �ra��1 mix m�:c�. 91 i0
Manufacturer's name
Sallt�� f�1�a� �Jllj@ gj2Cl• 1�2 11 Modelnumber HP 1 Volts 2��
Length of drop pipe ��� tt. Capacity '�� g.p.m.
sand �Zx �EC�• 1�5 �� Type: �ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS 5C
$y�jl(��T (�,1,a�! rQd ���' j� Does property have any not in use and not sealed well(s)? ❑ Yes O'ICo
SOf�. �'L V 1� VARIANCE
5a�u & �r����j �jX �l�d• 1�a .�� Was a variance granted from the MDH for this well? ❑ Yes ❑�
WELL CONTRACTOR CERTIFICATION
Use a second sheet,if 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.
i��S i��ll Dril.lin� �72?6
Licensee Business Name Lic.or Reg.No.
•�^' ....� /.
''�-r` �'�i-.;-�-�., �/.�'>��
.4uthorized Representative Signature�� Date
Rabert E. ��c,ciola, �.o��
_ �1�2/00
Name of Driller HE 01205-06(Rev.9/97)
LOCAL COPY i� 2�.5 6 7