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� WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD � <br /> ��j��g�y�,� Minnesota Statutes Chapter 1031 615 5 8 7 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> Cirono I18 23 3fi �. �. �, 2f�6' 1-29-�9 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 7$1 ��rndale �LC�� 1�. �L'OT10� � ;����� n CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �J Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ � <br /> Showing property lines, � <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> N <br /> , , , , �entonit� FROM n.ro_ n. <br /> -; -;- -;- -,- <br /> USE ❑ Monitoring O Heating/Cooling <br /> � � i � �J Domestic ❑ Community PWS ❑ Industry/Commercial <br /> _i_ _�_ _�_ _i_ ❑ Irrigation <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> W E T ❑ Test Well <br /> i i i i ❑ Dewatering ❑ <br /> i i i i +2IM_e � CASfNG Drive Shoe? � Yes ❑ No HOLE DIAM. <br /> _�_ _i_ _i_ _i_ � � `�I L � Steel ❑�(hreaded ❑ Welded <br /> ' ' � � ` �� w��" ❑ Plastic ❑ <br /> S '�t X <br /> �-1 Mile--i ^�' <br /> y CASING DIAMETER WEIGHT � <br /> PROPERTYOWNER'SNAMEL�"y � in.ro__2�_ft. 1 � Ibs./ft. �in.ro��ft. <br /> �t� -� in.to ft. Ibs./ft. 1 in.to�.�t. <br /> � <br /> Property owner's mailing address if erent than well location address indicated above. in.to ft. Ibs./ft. i ,m -7�,� <br /> U��7 <br /> 3436 'fOt.�1 S�• �v�•�' • SCREEN OPENHOLE <br /> Make �r,t/A from ft.to ft. <br /> 811��i��QI �i�i• rJ�J.31 .� TYPe Diam. <br /> SIOUGauze Length <br /> Set beiween ft.and ft. FITTINGS: � <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME ft. C�rbelow ❑ above land surface Date measured�_�,_`n� C� <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicafed above. _��y�_ ft. aRer hrs.pumping �]!�_g.p.m. <br /> WELL HEAD COMPLETION <br /> Model <br /> ❑ Casing Protection ❑�in.above grade <br /> ❑ At-grade(Environmental Welis and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? Oj�Yes ❑ No <br /> GEOLOGICAL MATER�ALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete C�High So�ids Bentonite <br /> MATERIAL _$_ __�� �_ Y � 9 <br /> from to ft. ❑ ds. ba s <br /> from to ft. ❑ yds. ❑ bags <br /> _ t � from to ft. ❑ yds. ❑ bags <br /> NEARES <NOWN SOURCE OF CON,TqAM�INATION -7-J f <br /> � feet /LlQ�T�_direction �� l 1 C rype <br /> Well disinfected upon completion? g(Yes ❑ No <br /> , PUMP <br /> ❑ Not installed Date installed `3�2 1�9� <br /> Manufacturer's name MvA t�Q <br /> Model number HP_�_ Volts �3� <br /> Length of drop pipe �.G V� ft. Capacity 1 V g.p.m. <br /> Type: 19Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes L�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes C7'No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Uvt3 S��IiOLA WELI� DRILLI�tG �O. , IN�C <br /> Licensee 8 siness N e�'� Lic.or Reg.No. Z,'1,�2 <br /> t''---'---�,+ <br /> xo-z�-gg _ .� <br /> uthorized eqres r tive Signatu Date <br /> Frer� L�iay 1-29-99 <br /> Name of Driller Date <br /> LOCAL COPY � �� � 8� HE-01205-06(Rev.9/97) <br />