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a <br /> t <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name I WELL AND BORING RECORDNwaNdn /;� � <br /> Minnesota Statutes,Chapter 103.1 (' 2 6'4`1 5 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Fl. <br /> / / <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds <br /> Cable Tool ❑Driven Dug <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number i Auger 'Rotary Ll Jetted <br /> 10" T@Mrwk Dr- Opno DRILLING FLUID WELL HYDROFRACTURED? Yes 2rNo <br /> Show exact location of well in section grid with"X". Sketch map of wed1a tion. Nater FROM ft.TO ft. <br /> Showing operty ine <br /> N roa and but USEMonitorin <br /> Elg ❑Heating/Cooling <br /> omestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> _Noncommunity PWS ❑Irrigation ❑Remedial <br /> Community PWS ❑Dewatering ❑ <br /> J CASING HOLE DIAM. <br /> w ET Drive Shoe? , Yes ❑No <br /> __;---- -____ I steel Threaded ElWelded <br /> 'h Mile [_1Plastic Elr 1 <br /> CASING DIAMETER WEIGHT <br /> 3 ___;(�in.to_ �ft. � lbs./ft. -a—in.to�_ft. <br /> 1 Mile—� <br /> in.to ft. lbs./ft. 41Lin.t237.11. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. to ft. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make FROM ft. TO5 ft4 <br /> BMW as ab m Type Diam. _ <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL 1 <br /> ft. elow El above land surface Date measured 8-315 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> .y �i� <br /> ZZS ft.after a hrs.pumping `0 —9-p.m. <br /> � r <br /> WELL HEAD COMPLETION <br /> ;p <br /> Well owner's mailing address if different than property owners address indicated above. pitless adapter manufacturer ter Model y/ <br /> ❑Casing Protection ,lel 12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted X.Yes ❑No <br /> Grout material ❑Neat cemei❑Benue ❑Concrete;ligh Solids Bentonite <br /> from to ft. Ia3 — s. >9 bags <br /> fromtc ft: '""""` S. ❑bags <br /> GEOLOGICAL MATERIALSCOLOR HARDNESS OF t <br /> FROM TO from o t. ❑bags <br /> MATERIAL f ❑yds. <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> w. <br /> el Jim beo= Daft 0 <br /> feet direction -. type <br /> Well disinfected upon completion XYes ❑No <br /> PUMP <br /> el ay Rnft 13 ❑Not installed Date installed 9-1 <br /> —05 <br /> Manufacturer's name <br /> f% ! t <br /> 2 Model number �l HP 1.-5 volts3 <br /> Length of drop pipe 126 ft. Capacity g.p.m. <br /> Type:XSubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> r,I ay bmwn tz+ ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) ❑Yes No <br /> VARIANCE h�o�c'' <br /> Was a variance granted from the MDH for this well? [:]Yes ;mMo 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. Don Staiola Well Drilling Co.,, Inc. 2X72 <br /> Licensee Business Name �'�D Lic.or Reg.No. <br /> or/zed Representative S` ure /� fh,' <br /> — +' Date <br /> L+d1uck L'�re <br /> LOCAL COPY � 726435 Name of Driller HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />