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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 612 6 5 4 <br /> i�B�lliB�lfl Minnesota Statutes Chapter 103! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(comple[ed) Date Work Completed <br /> fl. <br /> :���no 11�i 23 33 ,�. �. �. 225 7i�41�� <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD � <br /> 74t3 Go13�n View �L�.V� QY"(jt1 ❑ CableTool ❑ Driven ❑ Dug <br /> • ❑ Auger ❑�{otary ❑ 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 HYDROFRACTURED7 ❑YES C�NO <br /> " ��.C'=C_ �! „/'"_ riat�r <br /> , , , , FROM n.�o n. <br /> -,- -;- -;- -,- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i � � i _ tp.� ❑]Qomestic <br /> _i_ _� � � ..� ❑ Communiry PWS ❑ Industry/Commercial <br /> i i i ❑ Irrigation ❑ Noncommunit PWS <br /> w E ❑ Test Well y ❑ Remedial <br /> i i i i ` ��+.�'_ , { ❑ Dewatering ❑ f <br /> -r -�- -r- -r � . l �'1'�i.!'�4� '�: <br /> i i i i CASING Drive Shoe? ❑ Yes ❑f�o HOLE DIAM. <br /> VzM�ie f� i <br /> _� i _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i - i- i i <br /> ❑�lastic � 1 ,�,�� <br /> s --qz'-cr <br /> �1 Mile� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to_��_ft. Ibs./ft. _�_¢in.to�ft. <br /> l" <br /> t.L3����G��I�'LY.Z� £Y�(,'1G:�I{ in.to ft. Ibs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. � Ibs./ft. in.to ft. <br /> ���J +�IO�Ct� �.L S�a�i'��� Lt�Tlt�. SCREEN OPEN HOLE <br /> ��y��{�u��jt L'� ����� Make - from ft.to ft. <br /> Type 1rV Diam. -. <br /> Slot/Gauze � � Length �l <br /> Set between �'7 n ft.and_��_ft. FITTINGS: <br /> STATIC WATER LEVEL , <br /> WELL OWNER'S NAME �l�► tt. I]K below ❑ above land surface Date measured]�Q�� <br /> PUMPING LEVEL(below land surface) <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 <br /> � Pitless adapter manufacturer �`��..��$ Model ��� <br /> ❑ Casing Protection ❑�2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? C�,i'es ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material 6�leat cement ❑ Bentonite ❑ Concrete ❑ High So�ids eentonite <br /> MATERIAL from c3 to__,_�_�_ft. �?C1 ❑ yds. ��ags <br /> from to ft. ❑ yds. ❑ bags <br /> ::iay y,�ilc�;ri �,3 1 from co n. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ��o� ���y� �� �i feet direction � type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> V�Gi� �Y �i�V�L :3ttU� .�6.t l? PUMP ��*�n� <br /> ❑ Not installed Date installed � j <br /> '.sZ'i3Vt��. iBj.X'�':i �7,� c� Manufacturer'sname °"�]' `t-'r� <br /> Model number HP � Volts <br /> i.�.�� � j r;�v�� �`r�` �7 1� Length of drop pipe 1�� ft. Capacity 1'�� g.p.m. <br /> 7 �1 Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ila {�c �ro��7�'1 .��� f ��+ � � ABANDONED WELLS , <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Ri.No <br /> �anc� & ravel rz 1 �5 �2 � <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑�io <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOUFjrE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Steven� �rillin & E -. II�,�54 <br /> . �� � � ���� " License4 Business Name � F Lic.or Reg.No. � <br /> 4` ! <br /> � � f� `i+>,,,�„��'"��'r� � <br /> 4 i�-� �•. .S i '�'.,, . � e <br /> ''' Authorized Represenl8tive S�gnafure Date <br /> ..,i S � _. �a�Y�a��� <br /> �artdy �t,7Joh.��r�n <br /> Name olDriller HE 01205-06(Rev.9/97) <br /> LOCAL COPY �'j�.�� �j � <br />