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. � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> . ��CountyNanle WELL AND BORING RECORD 5 7 3 �6 8 <br /> A�nnepin Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> C�r.r,�no 198 ::� �7 ,, ,. ,. i€;� ` " l-1 �:-�� <br />�� House Number,Street Name,City,and Zip Code ot Well Location or Fire Number DRILLING METHOD <br /> C ❑ Cable Tool ❑ Driven ❑ Dug <br /> 711 � C�x F�rm Rca Orono,�IN. <br /> ❑ Auger � Rotary ❑ Jetted , <br /> Show exact location of well in section grid with"X". �- Sketch map of well location. ❑ <br /> �?-��6 Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> - N - � B�Ilt'.0711}.i: <br /> � � � � <br /> - ___ _-_ _ � <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i Domestic �y ❑ Indust /Commercial <br /> -�- -a- -�- -�- � � ❑ Irrigation � Communi PWS ry <br /> i i i i � �/ ❑ Noncommunity PWS ❑ Remedial <br /> w E T X ❑ Test Well <br /> i i i i ❑ Dewatering ❑ <br /> -r -�- -r- -r <br /> i i i i +/ZMia.0 CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> i i i i ❑ Steel ❑ Threaded ❑ Welded <br /> -� -�- -�- -i <br /> p Plastic ❑ <br /> s <br /> �1 Mile� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to ��� n. �DR'�� Ibs./ft. 1 ,���E 'i{' <br /> Fe�ture Builc�erC ,�.,o n. �bs.�n. ��,/�o=�f�4 <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> ��"1� Cabblestc�ne Ia�ne SCREEN �� OPENHOLE <br /> gt]Xj"jS V l,l 1,Q f �I2„ rj J 3�7 Make t from ft.to ft. <br /> Type ain �SS .r7�Q�1 Diam. ')n <br /> SIoUGauze ��if 1 V Length � ,+4 � <br /> Set belween �Z�. ft.and ��� ft. FITTINGS: � �—6 <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 4{-r,�f�O below ❑ above Iand surface Date measured �—�—g(j <br /> PUMPINC,.I�EL(below land surface) .� �1' <br /> Well owner's mailing address if different than property owner's address indicated above. � ' ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION �y���e��y��, <br /> Xl Pitless adapter manufacturer li Model <br /> ❑ Casing Protection �2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �7 Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑�entonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL <br /> from��to_�_ft. � O yds.$I bags <br /> from to ft. ❑ yds. ❑ bags <br /> C1�3y YeIZ� S G ' �U from co a. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CO AMINATION <br /> / r <br /> l.Zc1�7 Grey � �:ti � ��I j ��. teet Y/'C�� direction ���' °' �type <br /> Well disinfected upon completion? �T Yes ❑ No <br /> Clay-Gravel Brown M 1 1� 13C:� PUMP 3-I2-96 <br /> ❑ Not installed Date installed <br /> L�nd �3anC� s t��y �f}C� Manufacturer'sname �:ed Jacl�et <br /> Model number HP_���Volts ?� <br /> Length of drop pipe 1!SC ft. Capacity g.p.m. <br /> �.'ryiuI1C� & Grav�:l �1X@t� ..ri—� �4� �8� Pressure Tank Capaciry �}3 X -T'Y'1� <br /> Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ 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 trom the MDH for this well? ❑ Yes �No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota fiules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> AON S'I'UUOIIA ��lELL DkILLZNG CO. , II�C. <br /> License usiness Name Lic.or Reg.No. , j l <br /> �--_ ' 1-i�-96 <br /> .-:,. � <br /> Authonzed Representative Signatu e Date <br />� �'rec3 Le.i k�y 1-12-96 <br />� Name ol Driller ME 01205-05(Rev.1/95) <br /> LOCAL COPY � � � � 6 $ <br />