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, . <br /> :� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL RECORD '� ty�-+� <br /> F{ennepi n Minnesota Statutes Chapter 1031 �� '� � � F-� � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orono 117N 23W ��32 SE,,.SW,, NW ,,, � 132 "� 11/34/93 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> 480 Deborah Dri ve ❑ Cable Tool � Driven ❑ Dug <br /> ❑ Auger ❑ Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map o(well location. ❑ <br /> Showing property lines, <br /> ry roads and buildings. DRILLING FLUID <br /> I � _1 _1_ <br /> --�--,- , , None <br /> i � i i ,USE �Domestic ❑ Monitoring � Heating/Cooling <br /> �-+- �-- �- �- � Industry/Commercial <br /> W 'X ; � E ❑ Irrigation ❑ Public <br /> _1_ _1_ __ __ T ❑ Test Well ❑ Dewatering � Remedial <br /> � � i � <br /> �""'� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- �- ; -r- I �Steel ❑ Thre�q:�.Q ❑ Welded <br /> ' 1 Plastic ❑ ��� <br /> �—1 mife� <br /> CASING DIAMETER WEIGHT o <br /> PROPERTY OWNER'S NAME 4 in.ro 1�7 ft. Ibs./fl. v� in.tol`�2ft. <br /> Michael Pierce ��.to ft. Ibs./R. in.to n. <br /> Mailing address if different than property address indicated above. in.to ft. __Ibs./ft. in.to fl. <br /> 480 Ueborah Dri ve SCREEN OPEN HOLE <br /> Miaple Pidin� i��n. 55359 Make � from �.�o �. <br /> � Type �� Diam. <br /> SIoUGauze � Length 5� <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO #.3 ft.� below ❑ above land surface Date measured <br /> MATERIAL <br /> PUMPtNG LEVEL(below land suAace) t <br /> C 1� Yel�O�P/ O 1$ ft. after hrs.pumping �`� g.p.m. <br /> C �W�EtLL HEAD COMPLETION <br /> Clay Gray 18 VO IJF'itlessadaptermanufacturer ��SS Model ��� <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> Clay& Sand Gray 60 �V� GROUTINGINFORMATION <br /> Well grouted? �I Yes ❑ No <br /> Sand & Gravel Mixed 105 132 Grout Material � Neat cerp�nt ❑ Bentonit(g� <br /> from V to 3`� ft, ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? C�Yes ❑ No <br /> PUMP <br /> � � ❑ Not installed Date installed ��`���Q� <br /> - � Manufadurer's name <br /> Model number HP Volts <br /> Length ot drop pipe � ft. Capacity g.p.m. <br /> Pressure Tank Capacity <br /> MAR + ��� Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> . <br /> . �^ ^ r1A t n <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �I 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 /> Use a second sheet,il needed __��eYGIIS ���� ori 11 i na Ca I n� r��5634 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name � � Lic.orReg.No. <br /> Authorized Representative Signature Da e <br /> Dri Date <br /> LOGF�L COPY 5 3 0 2� � HE-07205-04(Rev.S/92) <br />