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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD -- -- -- A �. <br /> Minnesota Statutes,chapter 103I ti b b 5 <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> z n. <br /> j/4 1/ i/4 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool E Driven ❑Dual Rotary <br /> ❑Auger C Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. '' From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling <br /> 1 1 1 - ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> _J___1I L___ <br /> -._ El Community PWS ❑Dewatering ❑Remedial <br /> 1 1 I 1 <br /> _� CI___,_ __�___,__ ❑Elevator <br /> w E CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM. <br /> —,- T r I T ❑Steel ❑Threaded ❑Welded <br /> 'I/z Mile ❑Plastic ❑ <br /> -`` - ` " <br /> 1 CASING <br /> S Diameter Weight Specifications <br /> F- <br /> I- 1 Mile ` in.To ft. lbs./ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. n.To ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> Property owner's mailing address if different than well location address indicated above. SCREEN yes s OPEN HOLE <br /> Make , o h n s o n From ft. To ft. <br /> Type sta1n1'o tis Diam. '"3"I <br /> i <br /> Slot/Gauze •��2 Length -r <br /> Set between 175 5 ft.and 185 ft. FITTINGS 3 t l r-,3.t <br /> STATIC WATER LEVEL ft. ;y Below ❑Above land surface <br /> Date measured 1 0. 5 •2 2 _ Dry hole ❑Yes IM No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after hrs.pumping g.p.m. <br /> - <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer wh 1 t awa t a r Model <br /> ❑Casing protection []12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material cut t 1[fig rom 175 To 4 ft. ❑Yds. ❑Bags <br /> ,denton1 <br /> Material km,, 50 To ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ,- Septic t e <br /> Well is feet direction fromyp <br /> Well disinfected upon completion? ❑Yes No <br /> r7 1 " PUMP❑Not installed Date installed I 0/11/2 <br /> Clay/San -. Manufacturer's name S hater <br /> Model Number HP Volts <br /> land Brown 1 : , <br /> Length of drop pipe 126 ft. Capacity . g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating El Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes ❑No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes LI 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 /> •z 11' ' 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> ' ' -- <br /> r-------:- .. <br /> _,. <br /> F 10/12/2,. <br /> ert led Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 8 6 6 5 3 5 Name of Driller <br /> ID#52603 HE-01205.18(Rev.3/19) <br />