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�. _ , .. _ ,: . <br /> F , <br /> ,_,. , , :_. . �. •. <br /> . . ,. .:tw3•' . � . . . .., . � . ��. -� 4 . . ._ . ..-�� . .. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 3 913 0 <br /> gQIlI1e i n Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WEIL DEPTH(completed) Date Work Completed <br /> n. <br /> Orono 118 23 32 ,. ,. ,. 198• 12-23-99 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> d 5539 i � Cable Tool ❑ Driven ❑ Dug <br /> 3675 Jacobs �111. Boad Oroao, � ❑ Auger �[Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". • L Sketch map of well location. ❑ <br /> M � ing property lines, <br /> fj�pB� I'"� roads and buildings. DRILLING FLUID t WELL HYDROFFACTURED? G YES ❑NO <br /> N �DLODit� FROM R.lo ft. <br /> i i i i <br /> _i _i_ _i_ _i_ <br /> USE �R ❑ Monitoring ❑ Heating/Cooling <br /> i � � i 4` p Domestic ❑ Community PWS ❑ Industry/Commercial <br /> _i_ _�_ _�_ _i_ ❑ Irrigation <br /> � � i i �f ❑ Noncommunity PWS ❑ Remedial <br /> yr E T ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> i i i i I <br /> -r -�- -r- -r <br /> i i i i +/ZM.ia CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> i _ �_ _L_ i � ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> �Plastic ❑ <br /> s <br /> �-t Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �__in.to_�Z ft. SDBZ1 Ibs./ft. I�� 3QE. <br /> Jsf f 1ls�at ;�.to h. Ibs./ft. in to 198. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to tt. <br /> SCREEN OPEN HOLE <br /> �QI S 1 Bt Make�.ohnsoa from ft.to ft. <br /> Kin:teapolis, �• g540 Type Diam M <br /> SIoUGauze�l A_A1 A Length 4� + 4� <br /> Set between �,�_�ft.and198 ft. FiTTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME Qg� ft. �elow ❑ above land surtace Date measured� 9 <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. �A 5� ft. after I hrs.pumping 30 g.p.m. <br /> WELL HEAD COMPLETION �,a: <br /> �Pitless adapter manufacturer ��t.e�a y� Model <br /> ❑ Casing Protection _.__ �12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat ce�ent �Bentoy�t� ❑ Concrete � igh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from to j ft. ❑ yds. �.bags <br /> F��� c w* �Q from to ft. ❑ yds. ❑ bags <br /> ,i �'� from to ft. ❑ yds. ❑ bags <br /> NEARE f W1J SOURCE OF CONT INATI(� �`�� <br /> Cl$Y TQll�� s 1� 25 feet nCJ 1 �/ direction �..:�.- ���rype <br /> Well disinfected upon completion? �Yes ❑ No <br /> Clay Grey S 25• 90 pUMP <br /> ❑ Notinstalled Dateinstalled Z�27�00 <br /> Sand aravel HrO� � 90, ���,Manufacturer'sname ��ar`te <br /> Cldjt-GIaYl1 BIOI►11 S �34• 185�Model number 1 6 HP 1 vo15 23� 0 <br /> . <br /> Length of drop pipe ft. Capacity.. g.p.m. <br /> CDar�e 5•8n� ye110� S 1 p:7� 1 A7�Type: �ubmersible ❑ L.S Turbine ❑ Reciprocating ❑ Jet ❑ <br /> i 7 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �7 No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �I No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 lrue to the best of my knowledge. <br /> DON STODOLl� �+IELL DBILLING CO. . INC. <br /> _ Licensee iness Name i� , Lic.or eg.No. �''1'12 <br /> �� 3-2-00 <br /> _ <br /> Authori2ed� entative Sign ture -�' Date <br /> Fred Leiby 12-23-99 <br /> 6 3 913 0 Name o�Oriller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />