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<br /> .f ~ R MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/NQG NO. ELL
<br /> . WELL OR BORING LOCIATION
<br /> . CountyName WELL AND ��V..G RECORD � ������� ��,�-�. �
<br /> �� Minnesota St s,Chapter 1037 � ...s
<br /> - Township Name Township No. Range No. Section No. Fraction WELIJBORING DEPTH(completed) DATE WORK COMPLETED � �-
<br /> �D�fO �3� � � v< v< y R.
<br /> GPS DRILLING METH "?
<br /> LOCATION: Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds [.__�Cable Tool r 'Driven _-Dug
<br /> -- L,'�.Auger �Flotary j ]Jetted . -
<br /> House Number,SUeet Name,City,and Zip Code of Well Location or Fire Number ��
<br /> - �� �' t� � �'� �'� g� DRILLFNG FLUID WELL HYDROFRACTURED? . .Yes ' o .�
<br /> e✓
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location.� �� �$t�� From ft To
<br /> Showing property line �
<br /> � N roads,buildings,and directi . USE �- omestic ❑Monitoring LJ Heating/Cooling ��
<br /> �� ' ' L____1_ .�oncommunity PWS ❑Environ.Bore Hole ❑Indushy/Commercial '�� ��
<br /> '--- ' ,4
<br /> . 'Community PWS I]Irrigation n Remedial
<br /> 1----i- --`-----`-- . - '- � �.
<br /> � ,Elevator �]Dewatering �
<br /> � � — �__. - � ��:
<br /> '. '�'� , � , ET l.�a � CAStNG�MATERIAL Drive Shoe? ❑Yes �Vo HOLE DIAM. �#,,. �
<br /> �--- --�-----*- I � � �, .
<br /> ; ; ; �-___Steel j ]Threaded ❑Welded .
<br /> /z Mile "
<br /> I I , , � lasfiC ��
<br /> --�----�----�-----�- . . .
<br /> � �./ CASING
<br /> g � ''�j Diameter Weight Specifications
<br /> �1 Mile-�
<br /> `� �in.to_�__ft �IbsJft �__ � in,to�.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to _.ft. ___.___Ibs./fl. �in.to ���. �<..;:�:!
<br /> �5
<br /> 'G.�j T� ��2�..� in.to ft. Ibs./ft. _ in.to ft.
<br /> � �rany a! �S�tLEI OPEN HOLE ��
<br /> Property owner's mailing address if different than well location address indicated above. SCREEN _ .______ �'
<br /> Make_�� � From _ ft. To _ fl. :.;
<br /> � � �� TYPe ��B�Tl�Pl�_�.� Diam. .:
<br /> ._- -- -- ---
<br /> SIoVGauze_ !"1�'/1 Length_�_���_�•
<br /> �va:.r
<br /> Set between ft.and ft. FITTINGS �!iR
<br /> STATIC WATER LEVEL �s
<br /> �A Measured from �/��
<br /> .N ft.�_y�Below ,f-.j Above land surface Date measured J�7�'V�7�
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> L�►'°� ft.after �s� hrs.pumping 3J _g.p.m.
<br /> Well/boring owner's mailing address if ditterent than property owner's address indicated above. WELLHEAD COMPLETION ;.` . � �
<br /> �itless/adapter manufacWrer ���`-�"__.__*•,S;t�-.�--.s-°�-�-ry�odQh-- __
<br /> Casing Protection I,�Q2 in.above grade
<br /> j_�,,Ahgrade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted �(es _,No
<br /> Grout materials j�Neat cement ��lentonite 'i�Concrete '�Other
<br /> From O To_�Q fL �'/ 3�t�Yds. �Bags '�
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From ��@ _ To_ �q4�+'�` ft.��j �yW�. '�,�;Bags ,k
<br /> MATERIAL Fro�3t3_ .frii t����[,�ds. �Bags
<br /> To
<br /> NEAREST KNOWN SOURCE OF CONTAMINATlION
<br /> ��}��Z bJ�4:lE �� V 3 i � `...� feet /�✓ �' �.
<br /> direction �— ��a..,,.r-tq
<br /> ��g �y �} �pWell disinfected upon completion? es ❑No �, .,.,.
<br /> �6t�i gL'� �li J fA PUMP
<br /> �j .�-
<br /> ❑Not installed Date installed ! � � � "�� J
<br /> �� � ��� � ��� Manufacturer's name
<br /> ��t � �� `� � Model Number HP � (O�.Volts U��0
<br /> U�
<br /> ; �� t
<br /> Length of drop pipe y ft. Capacity g.p.m.
<br /> ��� ��1 �. . �t� 9t'�t �f�t L" Type:�' ubmersible [„_J LS.Turbine (�Reciprocating ❑Jet ❑
<br /> �t �i�41 i !V) 4i3
<br /> . ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? []Yes I- o
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? �_Yes � o 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,eta � - ���
<br /> �Q11 �LO��.l1��� ��1 f� C'��_T--�G.--.��.-
<br /> - Licensee Business Name Lic.or Reg.No.
<br /> � f. � ' � L
<br /> � - - !r �
<br /> i� d Representative Signatur� Certified Rep.No. Date�
<br /> LOCAL COPY � � 0 6 3 6 Name of Driller � � �
<br /> IC 140-0020 HE-01205-11(Rev.3/07) �
<br />
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