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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> ���-,�q Na� WELL AND BORING RECORD 6 2 4 9 61 <br />� � y Minnesota Statutes Chapter 1031 <br />� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Q I 8 23 3 ��a ��. ��. 237 12-£�- <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ D iven ❑ 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 />� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> N / <br />' _I I I I_ ! � ���`r water <br /> _� FROM ft.to R. <br />�t � -l- -�- -� .� USE � ❑ Monitoring ❑ Heating/Cooling <br /> i � i i .,., omestic <br /> _i_ _a_ _i_ _i_ ❑ Irrigation � Community PWS ❑ Industry/Commercial <br /> i i i i � ❑ Noncommunity PWS ❑ Remedial <br /> w E T � ❑ Environ.Bore Hole <br /> i � i i ❑ Dewatering ❑ <br /> k i i r i ,2IM_ie c^U� CASING Drive Shoe? ❑ Yes o HOLE DIAM. <br /> E _i_ _ i_ _� _ _i_ y ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i -�.,j <br /> 1 � �rPlastic ❑ <br />� s C 1� <br /> �--1 Mile--{ `+, <br /> CASING DIAMETER WEIGHT <br />�I PROPERTY OWNER'S NAME �_in.ro_�C�t. '��(�� Ibs./ft. �in.to_�Qt. <br /> 4 �{�v�� J h� in.to ft. _ Ibs./ft. G�.in.ro�' '�t. <br /> -v; <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> 109 Hackberry Tiili SCREEN OPENHOLE <br /> T ,�. t� A ` Make Johnson from ft.to ft. <br /> Lnl22�Zt$A�� M� �:�J�V TYPQ 9t���t,k�,g-�--PP� Diam. <br /> ' SIoUGauze A1 A Length ) f ,�, JL,�� - <br /> c� <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 130 R.�elow ❑ above land surface Date measured Z��8'�� <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 2�� ft. atter Z hrs.pumping �5 g.p.m. <br /> WE�,L HEAD COMPLETION <br /> �Pitless adapter manufacturer tsh# F avm t n r Model <br /> ❑ Casing Protection �12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION - <br /> Well grouted? ,�4es ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from�to_�Q_ft. ❑ yds.�'bags <br /> C1$v Ve11`�w .g{�Ft � ZS from_-3i�--to�7-ftn8t��-����!t� <br />� J J from to ft. ❑ yds. ❑ bags - <br /> t NEARESJT KN�(VN SOURCE OF CONT�AM+INATION <br /> Cila�� �r$y s�l t �5 40 �r•� feet L /'�S� direction�� �� ryp <br /> e <br /> Well disinfected upon completion? ,�4es ❑ No <br /> GRav�I, c co2ored mediurs3 90 125 PUMP <br /> n ❑ Notinstalled Dateinstalled II����'77 <br /> C1aylGravel �;r�►y �ediu� 25 ZG� Manufacturer'sname �g���$ <br /> r Model number HP_� Volts ��� <br /> watersand ;ray �QL� 20 ��� Lengthofdroppipe 160 ft. Capacity g.p.m. <br />�. �/ <br /> Type:,i6l 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 /> VAR�ANCE ` <br /> Was a variance granted from the MDH for this well? ❑ Yes �Jo TN# _ <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,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Don StQdola ��il Drillin�-= Ca. - Inc. 2 I72 <br /> ice e Business me- r-:� � �or Reg.� <br /> i� <br /> �-- .�_ _� 12-30-99 <br /> Authorized Repressrftative Signature Date <br /> Chuck Moore II-8-99 <br /> Name of Driller Date <br /> ; LOCAL COPY 6��4 9 61 HE-01205-06(Rev.7/98) <br />