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* ' �Z�CEIVE� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ' <br /> � County Name ]. 2006 WELL AND BORING RECORD -� � '� <br /> Minnesota Statutes,Chapter 1037 ; � c,,��� ,,,? <br /> ,� Township Name Township No. g N . Se � ction WELL DEPTH(completed) _ Date Work Completed <br /> n. <br /> ,i v< v. <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> � Longitude degrees minutes seconds �� I Cable Tool . �';Driven 'Dug <br /> `� �_J Auger �Rotary � Jetted t <br /> '; House Number,Street Name,City,and Zip Code of Well Location or Fire Number � /� . � � j <br /> DRILLING FLUID WELL HYDROFRACTURED? ^Yes '� No <br /> Show exact location o(well in section grid with"X". Sketch map of well location. lJG����=� FROM ft.TO ft. <br /> Showing property lines, <br /> ', N `� road�d buildings USE � Y '�Mo�nitoring �Heating/Cooling <br /> � � J � ' � � j�No cosmmund pWg -�Envaf'�nnBore Hole �!Industry/Commercial <br /> ;. ; � � Remedial <br /> � ❑Community PWS `J Dewatering ❑ <br /> � --'---—i------`-----`— . ' <br /> CASING HOLE DIAM. <br /> : w e T Drive Shoe� , J Yes �'No <br /> �. _,_____ �__ ;__ I '._',�Steei ']Threaded �,.]VJelded <br /> .. ? I ; 'h nniie •��_.�._._....,t lastic � <br /> --�--- --�-- --�-- ---%-- �i . ----- <br /> � � j CASING DIAMETER WEIGHT <br /> ; 1 I f I ; <br /> Y j �y/� +� ^ p q� <br /> y S ` .F. �. .......--"� +} � �GiJ L�ti� (7 � .71J <br /> � in.to ft. Ibs./ft. in.to ft. <br /> j 1 Mile� .� �.� --... —j— / <br /> in.to ft. ____ Ibs./ft. �in.to��'Tft. <br /> ; PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing address i(different than well location address indicated above. Make ��� FROM ft. TO ft. <br /> � �$ ailVYe TYPe $t$�tt�,,,p�R�� Diam. _ _ <br /> SlotlGauze _ /'�*� Length_ � <br />.. - lt! ----� --- �------- <br />� Set between ft.and it. FITTWGS N <br /> STATIC WATER LEVEL <br />� l�o ft. �� elow ,j above land surface Date measured � <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME ��Q A �j� <br /> �� ft.after & hrs.pumping .7t! g.p.m. <br /> WELL HEAD COMPLETION `` R-�-.� <br /> `�. Well owner's mailing address if different than property owners address indicated abeve. �'—' itless adapter manufacturer �J,`Cif ' Y ^r-- �� <br /> �asing Protection ��,�^j in.above grade <br /> [.Abgrade(Environmental Wells and Boring ONLY) / <br /> GROUTING INFORMATION <br /> Well grouted ,[3�'Yes ,_No <br /> Grou[material ❑Neat cement [�Bentonite � �Concrete �}(gFligh Solids Bentonite <br /> from }�� to +�� �ft. -7 � yds 1;yrDags <br /> from .7� to �L�V ft. �$���� ��d�. �,,'��bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to_ ft. �__yds. ]bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> :`1���feet ���.r..� direction �,�type <br /> Well disinfected upon completion � es ^No <br /> PUMP <br /> J Not installed Date installed ,�" �`�� �3 <br /> Manufacturer's name �' �� <br /> Model number HP 1/�Volts <br /> Length of drop pipe 1�-� ! tt. Capacity g.p.m. <br /> Type:_�� ubmersible ��LS.Turbine �Reciprocating ]Jet ❑ <br /> - ABAN ONED WELLS � <br /> Does property have any not in use and not sealed well(s) ❑Yes �;�IVo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed <br />�-�� REMARKS,ELEVATION,SOURCE OF DATA,etc. _ uV[i .7�(�(jQ�$ ►rC,l� �L.L��it9ty ��• 1I�C• 471/L, <br /> "4 <br /> Licensee Business Name Lic.or Reg.No. �i <br /> �.-... <br /> ... �:� /�a G la <br /> pre�n ative Sigrfatu Date <br /> �+li��[:7C ��' <br /> LOCAL COPY � � [,� � � � NameofDriller <br /> �1 :;�H601205-OB(Rev.5/02) <br /> '. IC 140-0020 <br />