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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 688976 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No.Taction WELL DEPTH(completed) Date Work Completed 1117 23 07 % <br /> v. 1% n. 9-23-04 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds [:]Cable Tool ❑Driven Dug <br /> ❑Auger Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Locationor Fire Number ❑ <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Shop exact location of well in section grid with"X". Sketch map of well location. Water FROM ft.TO ft. <br /> ��,` Showing property lines, <br /> ds and bwldings USE <br /> N "- ❑Monitoring ❑Heating/Cooling <br /> Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> !!!"`❑Noncommunity PWS ❑Irrigation ❑Remedial <br /> •�3fl ❑Community PWS ❑Dewatering ❑ <br /> t CASING c� HOLE DIAM. <br /> w e J� Drive Shoe? _]Yes ,p No <br /> ' T (� ❑Steel ❑Threaded ❑Welded <br /> h mile Plastic El <br /> ---- ---------- -- 1 <br /> CASING DIAMETER f }�WEIGHT <br /> 8 4 in.to 186 ft. 2 lbs./ft. V in.to 30ft. <br /> F--1 Mile y <br /> in.to ft. lbs./ft. in.to I% <br /> 194ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> Stonewwd DWiM %ild SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make � FROM ft. TO ft. <br /> "2Q Shoreline Tar Type stainlew stl Diam. r— — <br /> ��wn P*rkq M 553% Slot/Gauze Length LL9 4 Lt <br /> �'Ys'��,$o Set between19V ft.and ft. FITTINGS 27XW Wlkp <br /> STATIC WATER LEVEL +f��ht <br /> W ft.X below ❑above land surface Date measured 9 L'23"(A <br /> PUMPINGLEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME 184 ft.after__ 1.5 firs.pumping pit} gp.M. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer itr Model <br /> ❑Casing Protection f 12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes ❑No <br /> Grout material FLJ Neat cement ❑Bentonite ❑Concret.XHHigh Solids Bentonite <br /> from_ © to 4 30 ft. 2.5 [_]yds. bags <br /> a <br /> from 30 to 8 ft. =tUCS1 JUU ❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. ❑bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION a� <br /> clay brown Soft 0 20 feet direction _I <br /> p Well disinfected upon completion es ❑No <br /> Clay/swo ray soft 20 182 PUMP <br /> • <br /> ❑Not installed Date installed <br /> WaterSand ay soft 182 1% Manufacturer's name Aermtor <br /> Model number HP 1.5 Volts 230 <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type,.,y Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Ye No TN# <br /> WELL CONTRACTOR CERTIFICATION ir <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 se sheet,if needed on St�1a Well uLll� co,,. ,T.N. 2nn <br /> REMARKS,ELEVATION,SOURCE DATAeLicensee Business Name Lic.or Reg.No. <br /> 2-9-05 - <br /> A homed Rese ative Sigm ure Date <br /> 0** Moore <br /> LOCAL COPY F6889716 Nameo/Driller Daterle-olzos-oa(aev.5102) <br /> IC 140-0020 <br />