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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 3 3 5 8 9 <br /> ��enrie�in Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �rono lI7 23 6 �C,, S,y,; I�ys�. 12� ry 2/t3I00 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> 345 Narth Az'IIi Lri. Orana, M ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> j J 3��j Showing property lines, <br /> oads and buildings. DRILL�NG FLUID WELL HYDROFRACTURED? ❑YES,KL7 NO <br /> I N ` ._.'f_� T'ia G� � i.t� Si .' 'C'`Z FROM ft.to ft. <br /> -i- -i- -i- -i- <br /> g USE ❑ Monitoring ❑ Heating/Cooling <br /> _T= _�_ _�_ _i_ .L; xv\'� � Domestic ❑ Community PWS ❑ Industry/Commercial <br /> �-�_i. ti �. ❑ Irrigation <br /> i i i i " Jf +� _ � ❑ Noncommunity PWS ❑ Remedial <br /> w e t �� ❑ Environ.Bore Hole <br /> i i i � ❑ Dewatering ❑ <br /> -r -�- -r- -r <br /> � i i i ��z�ia CASING Drive Shoe? ❑ Yes $1 No HOLE DIAM. <br /> _i_ _�_ _i_ _i_ �'� ❑ Steel ❑ Threaded ❑ Welded <br /> i i i i � <br /> ;gl Plastic ❑ <br /> S <br /> �-1M'ile� ' `-.� <br /> �' CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME `� in.to I 1� � •g Ibs./ft. 8��in.to�� n. - <br /> Dav� t�iliia�ns Cc�nt. (� <br /> in.to ft. Ibs./ft. �in.to�vFt. <br /> Property owner's mailing address if ditterent than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make C'��"�' n from ft.to ft. <br /> 1 Q�i �• J't'C2 �ti• TYpe ��.d$� � Diam. <br /> �.�5 L:i t@ 1 SIoVGauze 1� Length �Q f t. <br /> C h�s y'a� t�;7f 5 5 31� Set between ��� ft.and ��� ft. FITTINGS: <br /> STATIG„�jTER LEVEL y 2/8 <br /> WELL OWNER'S NAME �~ ft. [i below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) � <br /> t�� <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after � hrs.pumping 3{� g.p.m. <br /> WELL HEAD COMPLETION <br /> '�] Pitless adapter manufacturer �+'}l l��k`r.�. �t'�Model �'� `�-�j1 <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ��7 Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete�] High Solids Bentonite <br /> MATERIAL from_��_to_�_.R. � ❑ yds.{� bags <br /> C�.a� �'�'O wT� ���)Z,� Q ?�� from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> c 1 a y g r a�r 3 C1�� �� 8..r's $0 feet �i�i S t direction S 8�'�1 C type <br /> Well disinfected upon completion? �Yes ❑ No t a r�'tf <br /> $f'9IICI S� ��,�.�' 17��WY) 30ft. ��J �O� PUMP <br /> ❑ Not installed Date installed <br /> sand br����i SOf+ 1�? ��� Manufacturer'sname �4� '7c�'�'`'���t <br /> Model number HP�V�Its <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type: ffi Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Ves t�j No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �,No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. 7he information contained in this report is true to the best of my knowledge. <br /> I��eatnne.r W�11 Inc. I�12� <br /> Licensee Business Nam� Lic.or Reg. o. <br /> f i � <br /> ,,,�,:�. - �. � �� <br /> uthonzed Representative Signa ure ate <br /> M�tiric� i:. Leuthn�r 3/3/�0 <br /> 6 3 3 5 8 9 Name ol Driller Date <br /> LOCAL COPY HE-01205-06(Rev.7/98) <br />