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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County,-me .. ._ WELL AND BORING RECORD <br /> � ::; <br /> Minnesota Statutes Chapter 1031 58G488 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> C�z'ono 11 1 2,CiG- n 10-8--96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 3G1Itirnhain Roan Orono, 114. 55359 ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". ap of well location. E1 <br /> Sho property lines, <br /> "oajcl buildings. DRILLING FLUID Bentonite <br /> N <br /> I I I 1 <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> IVDomestic ❑ Communi PWS <br /> El Irrigation �' ❑ Industry/Commercial <br /> I I I r ❑ Noncommunity PWS ❑ Remedial <br /> w, E �£L ❑ Test Well El Dewatering ❑ <br /> — - <br /> _r <br /> 112M, <br /> /z Mae t x CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> V. <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> [41astic ❑ <br /> s ` <br /> CASING DIAMETER WEIGHT _ / <br /> PROPERTY OWNER'S NAME t 1' in.to 191 ft. 1.9 lbs./ft. 7/� 3 <br /> ttC1l lel zst ky in.to ft. lbs./ft. — toy 1h <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. _in.to_ft. <br /> SCREENOPEN HOLE <br /> Make t from ft.to ft. <br /> Type s .c in 5v Steel <br /> Diam. <br /> Ll 1 t? Length <br /> SISlot/Gauze <br /> Set between j1 ft.and i {, ft. FITTINGS: "." '1S �Z_t t W <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME I<i' ft. C"below ❑ above land surface Date measured 10-8-96 <br /> -8` 96 <br /> PUMPING I.En(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping �'} air 9 p m <br /> ELL HEAD COMPLETION <br /> Pitless adapter manufacturer M1.tewater Model <br /> ❑ Casing Protection [$;12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 7P Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material EI Neat cement ❑;Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from (l t to 11'1 ft. ��, ❑ yds. C� bags <br /> KtY r y i t from t7 to ��� ft. .❑ bags <br /> 1 1( czi7 t .+-tqidie, <br /> from to ft. ❑ yds. ❑ bags <br /> &-Anel/Clay Grey/Hr S 1 10 1 1 fy t NEARS F gSpIN SOURCE OF COt�AMII�T�_ �— <br /> feet 2 fj,/$ � direction C type <br /> Well disinfected upon completion? EXYes ❑ No <br /> Water : rxi Grey r 185' 1C <br /> PUMP <br /> ❑ Not installed Date installed <br /> 1(.3—1"� 9 <br /> �3 <br /> Manufacturer's name �tda <br /> Model number 1 US 1 E�i 4'1LT, HP 11^- Volts t_;•f: <br /> Length of drop pipe1 t ft. Capacity I g.p.m. <br /> Pressure Tank Capacity �2 U X—TMI <br /> Type: ❑:Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes EN. <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes Oj No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,it 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 /> LX'fi 9,""OLS. WETS., MILLING (Xi., 1W-% 27174: <br /> ,,,L.:,ce,na Business Name ; ,.-�. _- Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Muck Mc.:0re 1 C-8-96 <br /> Date <br /> Name of Driller HE-01205-05(Rev.1/95) <br /> L(-,AL COPY 1586498 <br />