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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 4 8 0 2 9 2 <br /> "e`z t jn Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion <br /> It. <br /> Orono 117N 23W 10 NE,,,SE,,, NW,,, 125 05/23/92 <br /> Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD <br /> 1120 Ws 1 1 o i rive South � 0 Cablee Tool 0 Driven ❑ Dug <br /> 111AJW South 0 Auger X Rotary ❑ Jetted <br /> Show exact location of well in section grid with X. Sketch map of well location. ❑ <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> •_ <br /> I ir__7_ _.1__1_ None <br /> 1 <br /> 1 - 1 <br /> 1 i 1 USE <br /> W i i E ;i . K Domestic ID Monitoring 0 Heating/Cooling <br /> 1 0 Irrigation ❑ Public 0 Industry/Commercial <br /> 0 Test Well 0 Dewatering ❑ <br /> r <br /> Ib mi. CASING Drive Shoe? 0 Yes Sri No I HOLE DIAM. <br /> 1 <br /> __ _-— ——_r.. I 0 Steel 0 Threaded 0 Welded <br /> 1 <br /> r <br /> I--t milt Plastic glue <br /> Aum �p8 <br /> S '% CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME -1, 4 in.to 115 ft. lbs./ft. 8 in.425 ft. <br /> Tan Vi; -_. <br /> rrn in.to ft. lbs./ft. in.to ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make j'rP$�it from ft.to ft. <br /> 3065 Lab* Shore AvenueMake <br /> PVC SIA+' CAS1tY�Diam. 4 in,, <br /> Maple Plain, F 55359 <br /> Slot/Gauze 7�s� Length 10 ft.. <br /> 1 <br /> Set between 115 ft.and 25 ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> FORMATION LOG COLOR HARDNESS OF FROM TO 41 ft.jj1 below ❑ above land surface Date measured 06/23 <br /> FORMATION / <br /> PUMPING LEVEL(below land surface) <br /> ft. after hrs.pumping 50 g.p.m. <br /> Fill & Topsoil Mii3 0 15 <br /> WELL HEAD COMPLETION <br /> X Pitless adapter manufacturer Maass Model <br /> Clay & Sand Gray 15 40 li'"Casing Protection <br /> n GROUTING INFORMATION <br /> Clay y 40 1.00 ._. Well grouted? (X Yes 0 No <br /> Grout Material k Neat cement 0 Bentonite <br /> Clay & sand Gray 100 112 from _to 30_ft. 0 yds. 0 bags <br /> Clay with strip., from to ` ft. 0 yds. ❑ bags <br /> Of gravel strips110/1 112 1.25 from to ft. 0 yds. 0 bags <br /> ii7 NEAREST SOURCE OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Clay Blne 125 - Well disinfected upon completion? x Yes 0 No <br /> PUMP <br /> 0 Not installed Date installed 7/22/92 <br /> • Manufacturer's name Goulds <br /> pie <br /> Model number HP 1/2 Volts 230 <br /> Length of drop pipe 60 ft. Capacity 10 g.p.m. <br /> Pressure Tank Capacity20 <br /> Type: Jg Submersible ❑ L.S.Turb O Reciprocating ❑ Jet 0 <br /> ABANDONED WELLS <br /> Not in use and not sealed well on property? 0 Yes ii No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdication 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 /> r. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. .t.... /�`' or �. <br /> ` 1 .xtl"--�_ _ 06/23/92 <br /> Authorized Representative Siganture Date <br /> Randy ?MAW A6/23/92 <br /> LOCAL COPY 4 8 0 2 9 2 HE-01205-03(Rev.9/91) <br />