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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> ' CountyName WELL AND BORING RECORD 6 215 5 8 <br /> �����s�f� Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ti.�at20 I17 'l3 10 Nhi 5i�i IV6ti i:�`� tt 5!�/O(} <br /> �. ��. ��. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ��..jJ Carriag� LraC1� Qr�T��J 5� 7�. ❑ CableTool ❑ Driven - ❑ Dug <br /> ❑ Auger �Rotary � ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ <br /> Showing property lines, <br /> � f� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑ <br /> rv /� Y ' tiitlt��-'�' <br /> i , i , �FROM n.to n. <br /> -� -i- -,-- -i- ,- - _. __ <br /> USE ❑ Monitonng ❑ Heating/Cooling <br /> i i i i L�°Domestic <br /> _i_ _�_ _�_ _i_ � � ❑ Community PWS ❑ Industry/Commercial <br /> i i i i � ❑ Irrigation ❑ Noncommunit PWS� <br /> w E T � ❑ Test Well y ❑ Remedial <br /> i � i � "---�- -__ ❑ Dewatering ❑ <br /> i -, i -r +ZIMie '�x CASING Drive Shoe? ❑ Yes C��No HOLE DIAM. <br /> _i_ _i_ _L_ _i_ � .i � ❑ Steel ❑ Threaded ❑ Welded <br /> , � � � l . , <br /> C�Plastic ❑ <br /> S �.� <br /> �-1 Mile-{ . . .:..... . ........ . . <br /> '�'-+��L'-���- � CASINGDIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to ��� ft. ��� Ibs./ft. � in.to 3(Ei;� <br /> I.rE'G�� C�n��ruet�.�n in.to ft. Ibs./ft. �n.to-�R. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> �Q�4V V�K111� yrive, .S�a�r�' I,O� SCREEN OPENHOLE <br /> Eden :�rairie, i�N 553�4 Make a �� from n�o h. <br /> Type Diam. <br /> SIoUGauze Length <br /> Set between �54 ft.and 1�� ft. FITTINGS: <br /> STATIC Wij,,,T�t LEVEL _��5r , <br /> WELL OWNER'S NAME J� ft. L1'Delow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) . r, <br /> Well owner's mailing address if different than property owner's address indicated above. �� ft. after S hrs.pumping �v g.p.m. <br /> �LLHEADCOMPLETION ��lt@Wa�L�r S'�J��! <br /> Pitless adapter manufacturer Model <br /> ❑ Casing Protection ❑ 72 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Wellgrouted? �Yes ❑ No � <br /> HARDNESS OF Grout Material ❑ Neat cemeru. Bento ' ❑ Concrete ❑l�i Solids Bento t <br /> GEOLOGICAL MATERIALS COLOR MATEfIIAL FROM TO �� � � <br /> from to ft. ❑ yds. �bags <br /> o � from to ft. ❑ yds. ❑ bags <br /> r�anaY clay i�rvw�n ��ra. <br /> from to ft. ❑ yds. ❑ bags .. <br /> � � �4 12,� NEARESTKNOW`�NISOURCEOFCONTAMIN ATION <br /> �a�ai3 �la� blu� m�d. t! t1�tLlt �3€�f�f�.r j�3.�3i� <br /> feet direction pe <br /> Well disinfected upon completion? O`�7es ❑ No <br /> sac�c�y cla� r�ci �a�d. 1"l" 3� ' <br /> PUMP <br /> � �.�t3a��@ ❑ Notinstalled Dateinstalled J" �/�� <br /> ciay ar�;� sar�a <br /> k�321�� CUElru�' �.5 1� Manufacwrer'sname <br /> Model number HP Volts <br /> Length of drop pipe_ �20 ft. Capacity �� g.p.m. <br /> Type: LJ'Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS y � <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑'IOo . <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 /> tt�� YJ811 17�'1112 i�."y l 7 c 7� <br /> Licensee S3ysiness Name �` Lic.or Reg.No. <br /> r'�--�'K.�"� ."`;-�l��-� ���I �' � <br /> Authorized Representative Signature Da e <br /> xobart �:. Stoa.ola. Jr. 5/8/�U <br /> Name of Driller Date <br /> LOCAL COPY 6 2�. 5 5 8 HE-01205-06(Rev.9/97) <br />