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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD �g 5 01 � <br /> Hennep i n Minnesota Statufes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orano 11? 23 4 ,. �. ,. 181 n 1Q/9/96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> n�fn ❑ Cable Tool O Driven ❑ Dug <br /> 27G�J .�?���r8�� Lane Or�nfl ❑ Auger C�Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> ro3ds and buildings. DRILLING FLUID <br /> " Bentonite <br /> � � � � <br /> -,- -,- -,-- -,- G., � <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i C�Domestic <br /> ❑ Community PWS ❑ Indust /Commercial <br /> i i � i ^� ❑ Irrigation ❑ Noncommunit PWS ry <br /> w I I I I e \�,` ❑ Test Well ❑ Dewatering Y O Remedial <br /> \ <br /> i i i -r �/ZM,�a CASING Drive Shoe? ❑ Yes �QJo HOLE DIAM. <br /> _i � _L_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> ' ' ' ' Q(Plastic CpC .'�ZLI�C� <br /> s <br /> �1 Mile� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 9 in.to Z 75 ft. Ibs./ft. 8� i�,t�8 2 H. <br /> St i ckne & Schwarz ��.to h. Ibs./it. in.to n. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> ��7 Manitoba AII�• cJ���srl SCREEN OPENHOLE <br /> �7ayzata, MN 55391 Make Fv f�om tt.to n. <br /> Type T�lescop TIC� Diam._ <br /> SIoUGauze � Length � <br /> Setbetween 176 ft.and I8I fl. FITTINGS: R-Pac�er <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 2 fl0 ft. �6elow O above land surface Date measured 1����g6 <br /> Same PUMPING LEVEL(below land suAace) <br /> Well owner's mailing address if different than property owner s address indicated above. ft. after hrs.pumping !�� g.p.m. <br /> Sc�llle WELL HEAD COMPLETION <br /> OCPitless adapter manufacturer 1"id�S Model <br /> ❑ Casing Protection C�{I2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 9 <br /> from_�..tl to�ft. � ❑ yds. C�Lbags <br /> from to R. ❑ yds. ❑ bags <br /> �`��! .�30��. blaCk Q 2 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> �1 a y Y�11 OW 2 z(.� feet direction type <br /> Well disinfected upon completion? C�Yes � No <br /> c2ay gray 29 94 PUMP 1OJ21146 <br /> ❑ Not installed Da installed <br /> - Manufacturer's name �te��^r �£ <br /> sand & t�. rk�v$1 yellow g� 1�4 Modelnumber HP � �i Vo¢� <br /> �f1 Length of drop pipe �' f[. Capaciry 1 g.p.m. <br /> B 1 a� g r a y 1 L 1 1�� Pressure Tank Capaciry <br /> Type: q+Submersible ❑ L.S.Turbine ❑ Feciprocating ❑ Jet ❑ <br /> aan� yellow 1�46 181 <br /> ABANDONED WEILS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes LI No UL�kI���� <br /> VARIANCE <br /> Was a variance granted from the MOH for this well? ❑ Yes �Jo <br /> WELL CONTFACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was dritled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> �*Av�rc nri��ing �8�r�viron�zental 8665 <br /> Licensee Bus�ness Name Lic.or Reg.No. <br /> Authonzed Representative Signature Date <br /> Paul Swearinc�en 10/9/96 <br /> � !� Name ol Oriller Date <br /> . . - .. :�1 �, �V <br /> 9.. �y <br /> �",k E`� '.� '" � � HE-01205-05(Rev.1/95) <br />�. <br />