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.� :i. .� .,:('� ' ' y'.. . '� . � ..j�� ��' ..� , <br /> i.. • <br /> .. .. . . . �8...'.; <br /> :^ <br /> .. - . . ....+��F'+'T:.'�M . . . . ��. . . e. i✓.. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br />. . CountyName aenne ia WELL AND BORING RECORD 6 3 914 7 <br /> p Minnesota Statutes Chapter f03! <br /> Township Name Township No. Range No. Section No. Fractio� WELL DEPTH(completed) Date Work Completed <br /> n. <br /> 117 23 04 �,, ,. �,. 109' 3-3-00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 2685 Raine �Dad �r�QO� �• 5392 � CableTool Driven ❑ Dug <br /> Y ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid wit�)".. Sketch map of well location. ❑ ___ � � <br /> ���� Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO <br /> N <br /> , , , , �ater FROM n.,o h. <br /> -,- -,- -,-- -,- <br /> USE ❑ Moni[oring ❑ Heating/Cooling <br /> i i i i C7�omestic ❑ Community PWS ❑ Industry/Commercial <br /> _i_ _�_ _a_ -i- ❑ Irrigation <br /> � i i � ❑ Noncommunity PWS ❑ Remedial <br /> ,N E T ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> i i i i <br /> -r -�- -r- -r I <br /> � i i i '/zM e CASING Drive Shoe? ❑ Yes �No HOLE DIAM. <br /> i _ �_ _� _ _�_ � ❑ Steel ❑ Threaded ❑ Welded <br /> ' ' ' ' �Plastic ❑ <br /> s <br /> - �-1Mile-� <br /> CASING DIAMETER WEiGHT <br /> PROPERTYOWNER'SNAME 4 in.to 1� ft. ��$'�' Ibs./ft. 7�� 3�. <br /> TON BREN HOPiBS in.to ft. Ibs./ft. in.to�y�rt. <br /> Property owner's mailing address if diflerent than well bcation address indicated above. —__ in.ro ft. Ibs./tt. in.to ft. <br /> 7526 Turner ��ad SCREEN OPEN HOLE <br /> �nas�enae�►ce, t�N. 55328 Make �Q i 8 a from ,,.,o h. <br /> Type st��fllls� st�81 Diam. � A <br /> SIoUGauze Qj!3—A 1 R Length 4• f 4� <br /> Set between ��(�ft.and_�..QQ_ft. FITTWGS: 3� <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 5� R. �below ❑ above land surtace Date measured 3�3�0� <br /> PUMPINAG LEVEL(below land surtace) 7 <br /> Well owner's mailing address if different than propeRy owner's address indicated above. 7S ft. after a hrs.pumping 30�' g.p.m. <br /> WELL HEAD COMPLETION t�f� L <br /> ��itless adapter manufacturer Aaa��.e�a 4�r Model <br /> ❑ Casing Protection �12 in.above grade <br /> • ❑ At-grade(Environmental Wells and Borings ONLY) <br /> • GROUTING INFORMATvION <br /> Well grouted? LlAres ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete C�iigh Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO /� <br /> from__y�to_3Q_ft. __�'� ❑ yds.$ bags <br /> Clap—GraY@1 Y611 S �• 20 from __to n. ❑ vds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEARE � WJJ SOURCE OF CONTAMINATION <br /> Ciay C7reY � Z� �7 feet ��/L�� direction��rype <br /> Well disinfected upon completion? �Yes ❑ No <br /> y Sandp clay Hro 3 85 95 PUMP * <br /> G ❑ Not installed Date installed ��1�s00 <br /> Sand •AQ S �`� +O� Manufacturer'sname <br /> �e��s <br /> Model number HP�_�_�_.__ Volts�_ <br /> Length of drop pipe OR ft. Capacity g.p.m. <br /> Type: ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jel ❑ <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? ❑ Yes �No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i1 needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. _ <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The intormation contained in this report is true to the best of my knowledge. <br /> DON STODO�,,,�, T�tBLL DRILLING C0. • INC. <br /> Licensee B siness Name ,�Lic. r Reg.No. ��i�� <br /> +...�-�--". .- - <br /> .- 6-23-00 <br /> A orized epreseq,{c�f� Signature Date <br /> �aes� Leiby 3�3-00 <br /> LOCALCOPY <br /> 6 3 914 7 Nameo�Driller Date <br /> HE-01205-07(Rev.2/99) <br />