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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIc?UEWELL NO. <br /> �� CountyName WELL AND BORING RECORD {� <br /> Minnesota Statutes, Chapter 1031 � � � L?� � � <br /> Towns ip a Township No. Range No. �fiection No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> '/. '/< '/. Z 8"'�"'� <br /> G DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool j Driven Dug <br /> U Auger �Rotary Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � <br /> DRILLING FLUID WELL HYDROFRACTURED? [_I Yes .�Na <br /> Show exact loca i o we I i ection gri wit . �Sketch map of we!I location. "'�"•t�t� FROM R.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE <br /> ' []Moniroring ❑Heating/Cooling <br /> �-� I I I 1 , Domestic Environ.Bore Hole ',Industry/Commercial <br /> --'--- --'--- ---`-- ---'— � l_� _..,. <br /> �. j j ' 1 � � i Noncommunity PWS [ �Irrigation ❑Remedial <br /> ; � CASING M1 <br /> - � � � , �Community PWS �Dewatering ❑ <br /> � --'--- --i--- ---`- OLE D M <br /> . w ; ; ; � e T � Drive Shae?�Yes ❑No �A <br /> H <br /> ; __;___ _;__ ._�__ ___;__ I �Steel �-� �Threade �]Welded i�� <br /> � <br /> '/Mile ❑Plastic <br /> �.: --�--- --�-- ---�-----%-- <br /> 1 CASING DIAMETER WEIGHT <br /> g � � 4:, � <br /> "T� \,� _�__in.to �ft. ��Ibs./ft. �_in.to�_ft. <br /> �—�Mi�e� <br /> _ in.to_.___ ft. Ibs./ft. � in.t��ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. .t ft. <br /> �u�#� C SCREEN OPEN HOLE <br /> Property owner's mailing address if different than weil location address indicated above. Make FROM �� ft. TO ��� ft. <br /> � �+ a� Type Diam. _,_ <br /> Slot/Gauze Length <br /> Set between ft.and it. FITTINGS <br /> STATIC WATER LEVEL <br /> ft. below ❑above land surface Date measured <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(b ow land surface) <br /> ft.after hrs.pumping g.p.m. <br /> WELL HEAD COMPIETION <br /> Well owner's mailing address if different than property owners address indicated above. �Pitless adapter manufacturer �?Y�+� � n �• lvtodel <br /> ❑Casing Protection �12 in.above grade <br /> '�;At-grade(Environmental Wells and Boring ONLY) , <br /> GROUTING INFORMATION <br /> Well grouted es U No <br /> - Grout material �eat cement [_J Bentonite n Concrete�`High Solids Bentonite <br /> from _�__to�ft _� _yds. �,'bags <br /> from_�to_�_ft.�����tf[f�gs <br /> HARDNESS OF ��t��� <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from to ft. ;�yds. bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ��C b� �t V �L. :._!"''_� feet "�'`...� direction >._X_+. .,:..�S�a�.iat.yYPe <br /> Well disinfected upon completion ��es ��No ..:',�„A,,.,�, <br /> C� U�j L� lq 4Z PUMP J l <br /> 4 !"' � <br /> (_]Not installed Date installed �_�l " - � <br /> �+�$. f� �� �� Manufacturer's name - _ «--..� <br /> Model number HP�_��_Volts <br /> a`ii{Iiu $9 Lt � �1Q Length of drop pipe l�J� ft. Capaciry g.p.m. <br /> Type:� � ubmersible ❑L.S.Turbine ❑Reciprocating �;Jet ❑ <br /> �L�I 'ilO Z�AB DONED WELLS <br /> Does property have any not in use and not sealed well(s) 'L;Yes No <br /> Cl � b,� 'Ft 2W VARIANCE <br /> "'+"'�-`+ g`��� white/ Was a variance granted from the MDH for this well? ❑Yes - No TN# s� <br /> ""`+����t(�f t't �� �A WELL CONTRACTOR CERTIFICATION <br /> �V This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> RThe information contained in this report is true to Ihe best of my knowledge. � <br /> T•imE+$�� ��fieet,ifneeded r� �,' ��` <br /> Use a sec <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Business Name Lic.or Reg.No. <br /> i <br /> `�: /„�-G'/ <br /> or¢e presentative Signatur Date <br /> l+liLli�� �� <br /> LOCAL COPY � '`j �� �^ F,� Name olDiiller <br /> 1" �'} �3 HE-01205-08(Rev 5/02) <br /> IC 140-0020 <br />