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� <br /> r1�cLL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> oo� Name WELL AND BORING RECORD <br /> �`ennepin Minnesota Statutes Chapter 103/ 6 7 3 8 91 <br /> Towqs�ONanmeO Tow4sFup�. Range�p� Sectio�No. Fraction WELL DEPTH(compieted) Date Work Completed <br /> tJ 11 L 94 ry �i-8-02 <br /> v. v, v. <br /> Hou�ej�yipbe�$treQt=�me,G�tv and Zip1C=euo�f Wuell Loc�Si�p��� or Fire Number DRILLING METHOD <br /> �t��, iv e� t7C, u 7� ❑ Cable Tool ❑ Driven i i Dug <br /> I� Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. I I ._.____ ' <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O <br /> N �uper gei-x <br /> � i � i FROM fl.to ft. <br /> -� -i- -i- -i- <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i �omestic <br /> _i_ _�_ _�_ _i_ ❑ Irrigation ❑ Community PWS ❑ Industry/Commercial <br /> i i i i ❑ Noncommunity PWS ❑ Remedial <br /> w e T ❑ Environ.Bore Hole <br /> i i i i I ❑ Dewatering � <br /> -r -�- -r- -r <br /> i i i i ��M.i ,���� CASING Drive Shoe? ❑ Yes No HOLE DIAM. <br /> z <br /> _i i i i_ � p� ❑ Steel ❑ Threaded — ❑ Welded <br /> i i i i /V. <br /> � �lastic ❑ <br /> S <br /> �--1 Mile-� <br /> �,�,,, CASItNG DIAMETER WEIGHT s� <br /> PROPERTY OWNER'S NAME "� in.to 87 R. sdr`L1 Ibs./ft. 7�,� Q <br /> Ct$t t tiDy in.lo----Ft ---- Ibs./ft. �in.to y <br /> Property owner's mailing address if different than well loca[ion address indicated above. —____in.to_____fl. Ibs./ft. __in.to ft. <br /> $8�e a$ SUdV� SCREEN���/+r OPEN HOLE <br /> Make �'a.��� from ft.ro ft. <br /> � — �—r -___._---- <br /> Type__ P i C Diam. __ __ � <br /> SIoUGauze__..___�,�1.fl_____. Length __7� <br /> Setbe[ween ��/ ft.and_ ft. FITTING��i 1��`—o1s_7�G,", �•kC= <br /> �t----- �-1}— � <br /> STATIC TER LEVEL �� <br /> WELL OWNER'S NAME �� ft.�below ❑ above land surface Date measured �r��02 <br /> PUMPI (L'�EVEL(below land surface) q <br /> Well owner's mailing address if different than property owner's address indicated above. _ �V __ft, after _ ` hrs.pumping �S g.p.m. <br /> WELLHEADCOMPLETION Qhitewater <br /> � ❑ Pitless adapter manufacturer ____.____ Model _ <br /> � ❑ Casing Pro[ection ❑ 12 in.above grade <br /> ❑ At-grade(Emironmental Wells and Borings ONLY) <br /> � GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No �/ <br /> HARDNESS OF Grout Material ❑ Neat cem�t ❑ Bentonite O❑ Concret� X?High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from to 3p�R ❑ yds.�bags <br /> from�_to__�_�7_L n.118 t tlt�il_.f d�� bags <br /> �� SQiZ black s�lt � � trom to ft. ❑ yds. ❑ bags <br /> NEAREST KNO,�yN SOURCE OF CONTAMW9 TION <br /> ,{^" feet �+ '�� dlrection �rype <br /> C18 ��IDi�i 1S0$C Z� �.7 <br /> Well disinfected upon completion? �Yes ❑ No <br /> CIS C8 ISOft ].'� 78 PUMP <br /> ❑ Not installed Date installed � l�O� <br /> sand ts� .��lt 7C? 74 Manufacturer'sname ___ ___ae=��t�r <br /> Model number � HP Volts <br /> Length of drop pipe � ft. Capacity g.p.m. <br /> Type: ❑ Submersible f7 LS.Turbine ❑ Reciprocating ❑ Jet ❑ ______ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? C Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes D.G No TN# <br /> f <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 intormation contained in this report is true to the best of my knowledge. <br /> Dors Stodoia_�iell Dcil.2i�g Co. , Inc. Z 172 . <br /> Licensee Business Name ic.or Reg.No. <br /> �- .�- 7�L�V 4 <br /> uthorized Representatiy Signature ' - Date <br /> Duane Mathe�►s 4�-8-02 <br /> Name ol Driller Date� <br /> LOCAL COPY �7 3 g g 1 HE-01205-07(Rev.2/99) <br /> IC#140-0020 <br />