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x , <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD � 7 � �O o <br /> ���n Minnesota Statutes Chapter 103I <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed " <br /> Orono lI7 23 3 ,,. ,,. ,,. ., 207 " 7-22-�96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> �Gtl �TI�.y�� vLl� �QI� 5535b ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with�".1��+ " Sketch map of well location. ❑ <br /> �� Showing property lines, <br /> 1 (}� roads and buildings. DRILLING FLUID <br /> N � <br /> _� � � �_ X��Cl. Water <br /> _ ___ ___ _' <br /> USE ❑ Moniroring ❑ Heating/Cooling <br /> � � i � t�J Domestic ❑ Communit PWS <br /> _i_ _�_ _�_ _i_ ❑ Irrigation Y ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w I i ' E �� ❑ Test Well ❑ Dewaterin9 ❑ <br /> i i i i � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> VZn+ae <br /> _i i _�_ _i_ � ❑ Steel ❑ Threaded ❑ Welded <br /> � -�_ � � � Plastic ❑ <br /> s <br /> �-1 Mile� <br /> CASING DIAMETER WEIGHT 1 '�(� <br /> PROPERTY OWNER'S NAME 4 in.to 198 ft. '����' Ibs./ft. �� `����j'�'`7( <br /> ���1 �t�s bt su78� in.to ft. IbsJft. v$ in.to ""'ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to R. Ibs./ft. in.to ft. <br /> 1�.7`tO V 1 R[�'7 i�i� SCe 11Q SCREEN�_ OPEN HOLE <br /> Fxien Prairie, *8�1 553�►4 Make � St�� from ft.to ft. <br /> Type Diam. <br /> SIoVGauze Length <br /> Set between �7 ft.and_lg�ft. FITTINGS:11��M <br /> STATF6tY✓ATER LEVEL �! q� <br /> WELL OWNER'S NAME �� ft. � below ❑ above land surface Date measured �si <br /> PUMPIN('x►EVEL(below land surface) � /n <br /> Well owner's mailing address if different than property owner's address indicated above. Z�7 ft. after hrs.pumping �1J g.p.m. <br /> WELL HEAD COMPLETION T_A„1�tLI <br /> � Pitless adapter manufacturer ��i11 Model <br /> ❑ Casing Protection C?12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? L'S Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement C9 Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> MATERIAL _�__to�g. _'�_ ❑ yds. ❑ bags <br /> from <br /> Citi� `�g�'�� �ft Q '� from to ft. ❑ yds. ❑ bags <br /> j,r.. <br /> from to ft. ❑ yds. ❑ bags <br /> C�� tr�� ��t wy� A� NEARES � SQURCE OF CONT INATIOfy_ L/ <br /> er-•- ���� 1 feet 'i.J I rf �� � �� <br /> direction type <br /> Well disinfected upon completion? L9 Yes ❑ No <br /> Gr8Ve1 tffi1 SOfC lOC} 120 <br /> PUMP <br /> Ci $�a �1 t �4� 155 � Not installed Date installed ��7�� <br /> � � l Manufacturer's name _�Q�,t.�� �f�n <br /> Model number HP� Volts L..7t! <br /> .�`il� �$V .�,�t 1,rj5 �7� Lengih of drop pipe �S ft. Capaciry �R g.p.m. <br /> l <br /> Pressure Tank Capacity yC.���1 <br /> Cilgy �a� �it 175 195 Type: � Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> G`�1 �pll� �f t 195 ,W7 Does property have any not in use and not sealed well(s)? ❑ Yes L9 No <br /> .7" <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes L�No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if 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 hue ro the best of my knowledge. <br /> ao� st«�oi$ r��i �3zZ�; co., n�. Zn�z <br /> Licen ee Business Name Lic.or Reg.No. <br /> _�;;r ,�...�;r��� �-L�-�s� <br /> Authorized Representative Signature Date <br /> Fred �eiby <br /> Name of Driller HE 01205-OS(Rev.1/95) <br /> LOCAL COPY � ( � � '�O <br />