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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> � CountyName WELL AND BORING RECORD 5 7 2 710 <br /> ; Henne�in Minnesota Statutes Chapter 103/ <br /> �� Township Name Township No. Ran e No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ' Orono 1188 2� 33 E SE SE 79 tt 8/6/96 '% <br /> �. ��, �a ; <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD � ``[ <br /> 125 Hackberrp Hi21 ❑ CableTool ❑ Driven ❑ Dug ' ' `q <br /> ❑ Auger 7�1 Rotary ❑ Jetted� <br /> Show exact location of well in section grid with"X". � ` �'"� Sketch map of well location. ❑ �;� <br /> �`J / t Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N Bentonite <br /> _� � � �_ . � <br /> � -;- -,-- -, �� <br /> `�+ "^ USE ❑ Monitoring O Heating/Cooling <br /> -�,�. i i i i � � y �] Domestic ❑ Communit PWS ` <br /> _i_ _a_ _�_ _i_ tr C, � Y ❑ Industry/Commercial <br /> i � i i t�J Q) ❑ Irrigation ❑ Noncommunit PWS <br /> �� �J`- . fr� Y ❑ Remedial �� <br /> w e-r ❑ TestWell � <br /> � i i i ❑ Dewatering ❑ � <br /> i i r -r +2IM,ia CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i _i_ _i _ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i <br /> Xl Plastic ❑ <br /> S <br /> �-1 Mile-� <br /> CASING DIAMETER WEIGHT ; <br /> PROPERTY OWNER'S NAME 4 in.to 74 ft 200 �bs./ft. 8�in.to�� ft. � <br /> �h i 1 NQ 1� in.to fl. Ibs./ft. �in.to7 g ft. r <br /> Property owner's mailing address if diHerent than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE � <br /> Make �a �� from ft.to ft. � <br /> Type Diam. <br /> SIoVGauze Length � <br /> Set between ft.and it. FITTINGS: <br /> STATIC W TER LEVEL <br /> WELL OWNER'S NAME 3� ft. p(below ❑ above land surface Date measured <br /> PUMPI�,LEVEL(below land surface) 3 3 5 <br /> Well owner's mailing address if different than property owner's address indicated above. '3 1 ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> �7 Pitlessadaptermanufacture�itewater Model "S'e5�4 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? �l Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cem �Bent ite ❑ Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �'� � 9 <br /> from to ft. ❑ yds. ❑ bags <br /> (.'`],�y brovn al@d• � 37 from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> C.I.i3Y b2ue ,� 31 �Q� NEARESTKNOWNSOURCEOFCONTAMINATION <br /> t� �2 feet F' direction S�j��f� � <br /> Well disinfected upon completion? E'�Yes ❑ No a <br /> sand � r�ravel broWn med. �2 79 <br /> PUMP g/8/96 <br /> ❑ Not installed Date installed <br /> Manufacturer'snamen� �r$ <br /> Model number �J�Ju;"'� HP Volts <br /> Length of drop pipe 6� ft. Capaciry 1� <br /> Pressure Tank Capacity <br /> Type: �Submersible ❑ L.S.Turbine ❑ Fieciprocating ❑ Jet ❑ <br /> ABANDONED WELLS y <br /> Does property have any not in use and not sealed well(s)? ❑ Yes O-tJo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes xE] No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,ilneeded 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 /> R.E.S. Well �t'�lling 272�i <br /> Licensee Business Name Lic.or Reg.No <br /> � � r� <br /> ;-. . ,�- ��e�` �_ � '7 <br /> Authorized Representative Signature � D e <br /> Robert E. Stodr�la, Jr. 8/7/96 <br /> Name ol Driller Date <br /> LOCAL COPY 5 7 2 71 Q HE-01205-05(Rev.1/95) <br />