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* " ' MINNESOTA UNIQUE WELL <br /> WELL OR BORIh„�'.,LOCATION MINNESOTA DEF:ZRiT,1ENT OF HEALTH AND BORING NO. <br /> co„�ty hdme WELL AND F�(�R�NG RECORD �' <br /> Minnesota St$f,�i?Bs,Chapter 103I ���`.�� � a <br /> �,.. �4 :�i.. <br /> Township Name Township No. Range No. Section No. Fraction WELUBORWG�DEPTH(completed) DATE WORK COMPLETED <br /> 8 3S �'/ /�.�� lb3 n 8—l�-()S <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes ___ seconds _ <br />"`�"� Longitude degrees minutes seconds �.-Cable Tool Driven Dug _ <br /> �Auger ��Sota,ry .Jetted <br /> House Number,Sheet Name,City,and Zip Code of Well Location or Fire Number . �-_ <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes , o <br /> Show exact location of well/boring in section gri with"X° Sketch map of well/boring location. ��� From R.To <br /> Showing property lines, <br /> N � roads,buildings,and direction. USE . �omestic �..�Monitoring �]Heating/Cooling � <br /> ___ _ _ __ �.� � :�Noncommunity PWS �_.�Environ.Bore Hole ❑Industry/Commercial }'� <br /> �� , i_'�Community PWS �]Irrigation ❑Remedial <br /> f � ,/� <br /> --- - �i, r� '-i Elevator L]Dewatering ❑ <br /> � � � . ,1 <br /> J" <br /> w , , , E T "� � CASI{��'.,MATERIAL Drive Shoe? [I Yes �'�IQo HOLE DIAM. � � <br /> --;-----;-----�- --*- n <br /> , I � "" ' Steel I]Threaded ❑Welded . <br />�.. � � � � <br /> .. � � - '"' " �Mila ���www,,���"""'' �lastic `� - <br /> __;_____r__ __;_ � �, .� <br /> CASING <br /> S � �, Diameter Weight Specifications <br /> �—i Miie� �in.to�_ft ._��Ibs./ft. �$�� �in.to�J[. <br /> PROPERTY OWNER'S.,(yAME/COMPANY NAME _—_ in.to ft. Ibs./ft. �in.to ���. <br /> in.to ft. Ibs./ft. in.to ft �'� <br /> Property ownersmailing address if different than well location address indicated above. <br /> SCREEN�__ OPEN HOLE � <br /> 6� � 7� �t Make___ _ From eft To ft. �z <br /> A Type � Diam. _.-- ___- '� <br /> �I�$=af � ���1 Slot/Gauze # Length�������� <br /> Set between��ft.and�1 ft. FITTINGS 4 iL�'f �f/._� _ <br /> STATIC WATER LEVEL <br /> Measured from <br />� � ft�elow �_,'��Above land surface Date measured � <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ��� ft.after I..S hrs.pumping �� g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION .{�� � <br /> �itless/adapter manufacturer��4---�--��"���.`!!�I <br /> asing Protection ��2 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br />� Well grouted �(es �_]No �,,�C <br />� Grout materials _�Neat cement (�ttentonite �_�Concrete ❑Other <br /> From � To � ft � !���..Yds �ags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�To�f�f.a�w� ��Cds. ;]Bags <br /> MATERIAL From To ft. [�Yds. �Bags <br /> � NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � <br /> 4 1 �._�f'1 feet 3► direction rf% e <br /> �_ <br /> Well disinfected upon completion? �es ;J No <br /> � UMP <br />�.-���;��� ���. �.'� �� ., <br />�Sz-�� �.]Not installed Date installed ! <br /> � 1� Manufacturer's name �r:.�-�._?.J--1 <br /> )��,., <br /> Model Number HP__�.�JCVolts �� <br /> /� s- <br /> Length of drop pipe �{..f� ft. Capacity g.p.m. <br /> Type:�� ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet U <br /> ABANDONED WEILS <br /> Does property have any not in use and not sealed well(s)? ❑Yes '� o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? �,!Yes [�Q�o TNp <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. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Dt�n SLGdOla �11 DCiIIiclg t0,. it�e. 2�33 <� <br /> Licensee Business Name � � Lic.or Reg.No. <br /> __ �� �'i �� � � <br /> Ce ied RepresentativeSigFiature Certified Rep.No. Date , � <br /> LOCAL C�PY � � ��� �'} Name of Driller � � <br /> IC 140-0020 HE01205-11(Rev.3/07) <br />