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�:�.������ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORDSEP 2 8 1994 5 4 6 017 � <br /> Minnesota Statutes Chapter1031 ` <br /> ,r.� <br /> Township Name Township Na � Range No. Section No. Fraction WELL DEPTH(comple��.��'i. . � ' ork Completed <br /> n. <br /> 118 23 � . �. 167' b/28/94 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ 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 /> N roads and buildings. DRILLING FLUID � <br /> ' ' -� -1- Bentonite <br /> --r---�- i -� . <br /> i � � i� .USE ❑ Heating/Cooling <br /> ._+_ ___ �_ � omestic ❑ Monitoring <br /> � � ❑ Indust /Commercial <br /> yy � i � E Irrigation ❑ Public ry <br /> ' T ❑ Test Well ❑ Dewatering � Remedial <br /> -J- -?- -- =- � ❑ <br /> I � ' <br /> � r-mi. CASING Drive Shoe? ❑ Yes C�Jo HOLE DIAM. <br /> � ' <br /> ";' �' - -�' j ❑ Steel ❑ Threaded ❑ Welded <br /> �plastic ❑ <br /> �1 milr-� 7�� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME _�_in.ro��ft. Ibsltt. �i�,��.C I g. <br /> ��� in.to ft. Ibs./ft. in.to ft. <br /> Mailing address if ditterent than property address indicated above. in.to tt. Ibs./ft. in.to ft. <br /> 467� Creekvood Trail SCREEN OPEN HOLE <br /> Make�, from ft.to tt. <br /> iKaple Plain, MN 55359 Type te1 eoscopin� Diam. <br /> SIoVGauze i c7 Length S� <br /> Set between �62� ft.and 157 ft. FITTINGS: <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 71 ft.qQ below ❑ above land surface Date measured 6 28 g <br /> PUMPING LEVEL(below land surface) <br /> clay yeilow � 17 ft. after hrs.pumping 10� g.p.m. <br /> WELL HEAD COMPLETION <br /> L•la �rep 1'1 1'14 ❑ Pitlessadaptermanufacturer Model <br /> i <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> �and b gravel �ed y y� 1 35 GROUTING INFORMATION <br /> Well grouted? ❑ Yes ❑ No <br /> Grout Material ❑ Neat cement ❑ Benronite <br /> C13 r2d 135 149 from to e. ❑ ya5. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> ravel mixed 149 167 from �o n. ❑ Yas. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> PUMP <br /> ❑ Notinstalled Dateinstalled 8/29/94 <br /> Manufacturer's name MQ e=S <br /> Model number HP Vof[s� � <br /> Length of drop pipe ft. Capacity L g.p.m. <br /> Pressure Tank Capacity �a0 qa 1• <br /> Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> - Does property have any not in use and not sealed well(s)? ❑ Yes �No <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 /> Useasecondsheet,i/needed �tr@'V�I18 Driiling b BI1Y• 86654 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.orReg.No. <br /> , _.. <br /> �, . _._fi/28/94 <br /> Authorized Representative Signature Date <br /> Paul Swearingen 5/28/94 <br /> Name of Driller Date <br /> L�CAL CC7PY 5 4 6 017 HE-01205-04(Rev.5/92) <br />