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t <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 696471 <br /> B� Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ©rem 118 23 33 ,� ,/ ,, 253 h 8-27-83 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑ riven ❑Dug <br /> ❑Auger !Jf�Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location CL or Fire Number ❑ T <br /> 2W atertmn Rd. 5531V DRILLIINNGG FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Shop exact location of well in section grid w X". Sketch map of well location. "ento4te FROM ft.TO ft. <br /> mowing property lines, <br /> N 0,A roads and buildings USE ,,,/// ❑Monitoring [Heating/Cooling <br /> 1 Domestic ❑Environ.Bore Hole ❑Industry/Commercial <br /> Noncommunity PWS L1 irrigation ❑Remedial <br /> ❑Community PWS ❑Dewatering ❑ <br /> --i------------------------ <br /> CASING HOLE DIAM. <br /> yy E� Drive Shoe? EJ Yes Eo <br /> IEsteel ❑Threaded ❑WeRed <br /> l,M [)(Plastic ❑ <br /> --- ----'-'-- -- CASING DIAMETER s�`* WEIGHT /� <br /> 41 <br /> S ; 77 in.to 241 ft 2.A1 lbs./ft. in.to <br /> 1 Mile--{ <br /> in.to ft. lbs./ft. in.to <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. <br /> Sharon Ehlen SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. Make FROM ft. TO ft. <br /> Type stainlom St Diam. t <br /> Slot/Gauze .�� Length of + W # 4" <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL 8-2 <br /> �q <br /> 133 ft. elow ❑above land surface Date measured 8-27 <br /> —03 <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME30 <br /> 250 ft.after 3 hrs.pumping g.p.m. <br /> �Gasing <br /> L HEAD COMPLETION vhitemter <br /> Well owner's mailing address if different than property owners address indicated above. itless adapter manufacturer Model <br /> Protection _ �2 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted Yes ❑No <br /> Grout material Neat cement E]Bentonite ❑Concretetiigh Solids Bentonite <br /> fromQ_to 30 ft. 2_5 ❑yds. ) 6ags <br /> from 30 to2fil ft. TjotljCjd fft.1❑bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. ❑bags <br /> MATERIAL <br /> t NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Clay yellow Soft © 26 X00 feet J direction "- type <br /> p��p Well disinfected upon completion ss [3 No <br /> Clay 9r � 26 60 PUMP 8-2013 <br /> �p <br /> L-]Notinstalled Date installed <br /> Cra�V l colored �un 6© 120 Manufacturer's name Aermotor <br /> t q Model number HP ^Volts 230 <br /> clay brown medico 120 210 Length of drop pipe 168 ft. Capacity _g.p.m. <br /> //�� <br /> Type: ubmersible ❑L.S.Turbine ❑Reciprocating Jet <br /> fine Sand brown medium 210 238 ABAI,11DONEDWELLS <br /> w! soft <br /> �.�p Does property have any not in use and not sealed well(s) i�Yes o <br /> coarse Sand brooft 238 233 VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No 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. <br /> ilea-Stodolst ,Ian- 27172 <br /> Licensee Business me Lic.or Reg.No. <br /> thorize epre Live Signage Date <br /> Chuck Moore Z <br /> LOCAL COPY <br /> 696471 Name of Driller Date <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />