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WEf LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD pn� ^h 1 <br /> F1 7tt2e�� n Minnesota Statutes Chapter 103/ 8✓ v 2 1 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> C;'zc/I?C', 1 <br /> 7-18-97 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> !i,J1(i Zlrzcr uet l�Lreu L%,rie Drone tin. 5 <br /> L1 JiV. ❑ Cable Tool [I Driven <br /> [_1 Dug <br /> ❑ Auger ❑ Rotary ❑ Jetted <br /> Show exact location of w tion rid wi r, .,,-^j SkQtdh map of well location. ❑ <br /> howing property lines, <br /> -Toads and buildings. DRILLING FLUID BE'n l <br /> N }. <br /> �(1111 ,. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> y IXDomestic ❑ Communit PWS <br /> 71 Irrigation y ❑ Industry/Commercial <br /> ❑ Noncommunity PWS ❑ Remedial <br /> W I E T ❑ Test Well ❑ Dewatering ❑ <br /> CASING Drive Shoe? ❑ Yes A No HOLE DIAM. <br /> zMile <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> IA.Plastic ❑ <br /> s Xv�L�cr <br /> I Mlle <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME in.to t` - ft. 1 . 9 Ibs./ft. 3 i . <br /> in.to <br /> 'font, Eifien Cai:ip<�ny in.to ft. Ibs.ft. �.�� 5: <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> 'l 1100 Berkshire Leine <br /> SCREEN, _ OPEN HOLE <br /> Plymouth, Mn. 55356? Make t Johnson from ft.to ft. <br /> 1'J 4t 46 Type Ista n es Steel Diam. <br /> Slot/Gauze Length <br /> Set between _ 4 ft.and r_t: ft. FITTINGS: ° X (1 fr ;^ KP <br /> STATI ATER LEVEL <br /> WELL OWNER'S NAME el ft. f3.�)elow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> t�4? «;fin_; <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after < hrs.pumping 1 g.p.m. <br /> WELL HEAD COMPLETION <br /> 4-Pitless adapter manufacturer Wh i t E?LV a t:e r Model <br /> ❑ Casing Protection CZ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑Aes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement (X Bentonite ❑ Concrete ❑,High Solids Bentonite <br /> MATERIAL <br /> GEOLOGICAL MATERIALS COLOR FROM TO 3 <br /> from to ft. ❑ yds.13 bags <br /> from__ to ft. ❑ yds. ❑ bags <br /> ifl Jo;,.l Black from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Clay Brownf _ + feet direction type <br /> Well disinfected upon completion? 2-Yes ❑ No <br /> Cl&y Grey I S, [PUMP _ <br /> r <br /> ElO Not installed Date installed w�` ' C4 7 <br /> ce nG/Grcl.Z'4..3.�. C ,1'.1^ ({ i '� T '� (: <br /> Manufacturer's name Reel Jacket <br /> Model number y'-.7 9 S 8 I HP I Volts <br /> Length of drop pipe 14 Cpactty � g.p.m <br /> .1<y Grey `5 ,�O . <br /> Pressure Tank Capacity <br /> Clay <br /> 4,Submersible ElL.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> Clay Brown M 15 V I ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes X No <br /> Clci. /Boulders Brown B. ` �. <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes [XNo <br /> Z. Yellow 2 M 235 1' ' <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/needed This well was drilled 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 /> )ON STODCLA WELL DRILLING CO. , INC. 2-11-12 <br /> Licensee Businneas Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Chuck Moore 7-11D-97 <br /> Name of Driller Date <br /> 1... � .�._ f^(�PU 5 ; ? 1 HE-01205-05(Rev.1/95) <br />