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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 215 7 4 <br /> ���p���i� Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Orona 128 23 32 5�,�. 3� id�i,, 136 " 8/7�t3G <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> -c ❑ Cable Tool �C1.priven ❑ Du <br /> �b84 J�4obs i�i111 Rtt O7C4AC7� -):3�6 ❑ Auger o�ocary ❑ Jett d <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> �/{\ . Showing property lines, <br /> J roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> N <br /> i i � � -��- FROM ft.to ft. <br /> __ _i_ i i <br /> USE � ❑ Monitoring ❑ Heating/Cooling <br /> i i i i O�iiDomestic <br /> ❑ Community PWS ❑ Indust /Commercial <br /> i � � i y ❑ Irrigation ❑ Noncommunit PWS ry <br /> w E� �� ❑ Test Well Y ❑ Remedial <br /> � i i � ❑ Dewatering ❑ <br /> i i _r i �/ZM.1e . CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> _i i _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> i -i- i i <br /> Plastic ❑ <br /> S <br /> �i Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME __�in.to 2 3b n. 2i�C� 117.�Ibs./n. $ �.�. <br /> in.to g <br /> +�+`� ����� in.to ft. IbsJft. �in.to 1 3�R, <br /> Property owner's mailing address if different than well location address indicated above. — in.to ft. Ibs./R. in.to ft. <br /> C�� Lecy Con�struetioa SCREEN������,, �. OPENHOLE <br /> 1��4� Yfkin<,� Dr .�9t.� .�.�.! Make Cyj� ;�vV' from ft.to ft. <br /> �'l'�@17 Prasrie, �� ��J��#4 Type Diam. <br /> SIoUGauze Length <br /> set between Z��9 ft.and j.3E1 ft. FITTINGS: <br /> STATIC WATER LEVEL y <br /> WELL OWNER'S NAME � _ `,`'"� �$ ft. C?�below O above land surface Date measured $����� <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than pr'opetty etlGnBas a�4r�,s�indicated above. $a ft. after 3 hrs.pumping 3�'} g.p.m. <br /> � ''�f�l <br /> t-���:-- WyF��LHEADCOMPLETION �hit��a�ter .y���� <br /> ` '��.- - �'Pitless adapter manufacturer Model <br /> �''!, ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMAj�QN <br /> Well grouted? Q;'es ❑ No y <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete C�'High Solids Bentonite <br /> MATERIAL <br /> from_�_�to�ft. '� ❑ yds. ❑''�bags <br /> from to ft. ❑ yds. ❑ bags <br /> Cla 17111 Br�W�i St�f CJ 3 from co n. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> �lV� .�Q�1 �1��•,4� .��.�� .] '] �� feet ��+' ___direction 'S�`IT1�� "�7i�� <br /> Well disinfected upon completion? C�Yes ❑ No <br /> .7C1flCIy C�3�i BZO�II�I 1��� 7 4� PUMP <br /> ❑ Notinstalled Dateinstalled ����vV <br /> a�fl�,� ���,Y b��� ��a �'� �� Manufacturer'sname ���i�� <br /> Modelnumber 2�GSZU HP 2 vonits �J� <br /> Li�rc�t'�ir�l. � i'Jt�Cl:a` �.�.X ����� �� �'� Lengthofdroppipe I'Zv ft. Capacity 3v g.p.m. <br /> ��� �y <br /> Type: L3'�6ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> �rav�ei b Cla Mix b�e Coars 1"3" i:38 <br /> ABANDONED WELLS y , <br /> Does property have any not in use and not sealed well(s)? ❑ Yes CYNo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes ❑�IMo <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 ihe best of my knowledge. <br /> 1"tE� �v�l� U�iliin� 2"1276 <br /> Licensee Business Name�'"�` Lic.or Reg.No. <br /> i f <br /> �/ � l <br /> / t f . <br /> v��Authorized Representative Signature Date � <br /> Rot�srt E. Stodola, Jr. <br /> Name of Driller HE 01205-06(Rev.9/97) <br /> LOCAL COPY ��� �� Q- <br />