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a MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORDamme7 7 0 0 4 4 <br /> pin Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction ¢ WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> N4 <br /> Orow 127 23 07 $V SW, 219 12-1-M <br /> GPS LidDRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds L]Cable Tool ❑Driven ❑Dug <br /> ❑Auger :Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ J'�� <br /> 4510 Forth Shore Dr. Orow SS DRILLING FLUID WELL HYDROFRACTURED? Yes111mo <br /> Show exact location of well/boring in section grid with'X:' Sketch map of well/boring location. taj From ft.To ft. <br /> Showing property lines, <br /> roads,buildings,and direction. USE <br /> N Domestic [:1 Monitoring ❑Heating/Cooling <br /> Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> �\ ❑Community PWS ❑Irrigation ❑Remedial <br /> i <br /> ------ ❑Elevator ❑Dewatering ❑ <br /> `w E T CASING MATERIAL <br /> Drive Shoe? Yes �10 HOLE DIAM. <br /> --a----------------------- <br /> 'h Mile ❑Steel ❑Threaded ❑Welded <br /> ' Plastic ❑ <br /> - -----r-----------:-- <br /> 1 <br /> CASING <br /> "`''�'•.. Diameter Weight Specifications <br /> f1Mile� �+t-�a^.: { in.to 211 ft. 1 lbs./ft. Min in.to <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to <br /> Mdgrdew/Kathy <br /> Savi 4tekJ in.to ft. lbs./ftOPEN HOLE. in.to ft. <br /> �ii+R1 <br /> Property owner's mailing address if different than well location address indicated above. SCREEN <br /> Make JobinlRorli From ft. To ft. <br /> Sam Type �•t Diam. M - <br /> Slot/Gauze n4 n Length <br /> Set between .and ft. FITTINGS <br /> STATIC WATE L <br /> Measured from <br /> ft.VBelow ❑Above land surface Date measured + <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 2W ft.atter 1.5 hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer , <br /> Casing Protection 562 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes ❑No <br /> Grout materials Lj Neat cement 5JBentonite Concrete ❑Other <br /> From 0 To--50ft. 4 ❑Yds. [�+Sags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To=ft. tUltUrat ffli ❑Bags <br /> MATERIAL pra"j p& From-202—To ft. ❑Yds. Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay brown <br /> soft ----1,1�ao feet X / direction <br /> Well disinfected upon completion? es ❑No <br /> clayrsoft 16 4g0jPUMP / <br /> ❑Not installed Date installed <br /> S. Manufacturer's name <br /> Model Number HP_ Volts <br /> cidly/sarx! soft �+ <br /> Length of drop pipe f -7— ft. Capacity g.p.m. <br /> sandk,rayel soft 30 21 Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No 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,it needed. - <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Doa Stodols Well milling Co,. Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> r Cal'e Signature, Certified Rep.No. Date <br /> MIN& MOM <br /> LOCAL COPY � 770044 Name of Driller <br /> IC 140-0020 -- HE-01205-11(Rev.3/07) <br />