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',WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO <br /> County Name WELL AND BORING RECORD <br /> Hemewrpth <br /> Minnesota Statutes,Chapter 1031 715850 1 <br /> Township Name Townsh • <br /> hiip No. Range No. Sect+ioon No. Fraction WELL DEPTH(completed) Date Work Completed+� 2 <br /> 3 <br /> 11 Oran) <br /> $11 23W <br /> —04 <br /> GPS Latitude degrees _ minutes seconds DRILLING METHOD <br /> g <br /> LOCATION: <br /> Longitude degrees minutes seconds • 0 Cable Tool 0 Oiling'. 0 Dug <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑Auger VeRotary ' ❑Jetted <br /> •Lake <br /> 02,3 Old Dd. t DRILLING UID' • WELL HYDROFRACTURED? ❑YesX]No <br /> Show exact location of well in section grid with"X'. Sketch map of well location. Pts <br /> Showing property lines, ' FROM ft.TO <br /> ft. <br /> N * �... roads and buildings USE 0 Monitoring - <br /> ❑Heating/Cooling <br /> --• Domestic 0 Environ.Bore Hole 0 Industry/Commercial <br /> Noncommunity PWS ❑Irrigation ❑Remedial <br /> -•-i i'------t------t--- - 0 Community PWS 0 Dewatering 0 <br /> yy - CASING <br /> E Drive Shoe? HOLE-0IAM. <br /> ❑Yes No <br /> F i ❑Steel ❑Three ❑ ed . <br /> h Mile 1(�Plastic <br /> s <br /> 1 CASING DIAMETER T' IG <br /> HT <br /> --I in.to ft lbs./ft. al in.to ft. <br /> I---1 Mile <br /> ' In.to ft. lbs./ft. '!�, <br /> 2t in.toI ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> Darrial �' 011 <br /> in.to ft. lbs./ft. in.to $: <br /> SCREEN (OPEN HOLE <br /> Pr r ailih ad rens' r t than well location address indicated above. Make <br /> • <br /> ; , Mt S'�1 SbUGau2e F Diam. : ft. TO ft. <br /> LengID •th <br /> Set betweenLAW_ft.and 113 ft. FITTINGS t" . <br /> STATIC WATER LEVEL = <br /> ft. below,❑above landsurface Date:measured • � <br /> . <br /> WELLOWNER'S.NAME/COMPANY NAME • PUMPINf,LEVEL(below and surface) ., <br /> Darrell Anderson , � it.after hrs.`pumping q.p.m. <br /> Well owners mailin`address if different than propertyWELL HEAD CONtFPLETION <br /> 9 owners address indicated above. Pitless`adapter manufacturer Amps- ,Modef <br /> • <br /> acing Protection 0 12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING.IN FORMATION <br /> Well grouted Yes ❑No <br /> Grout materiel Neat cement Bentonite 0 Concrete <br /> �❑High Solids Bentonite <br /> from ' ft. ❑y'ds.. <br /> HARDNESS OF from to ft, . • ❑yds. bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL '.from t4 ,ft. ❑Yde ❑bags <br /> NEAREST KNOWN$OUROE OF CONfAMiNAON . <br /> ye .11 0 feet. . <br /> direction <br /> Well,disinfectetl uponcorylpleti©rt'iiYes ❑tie... <br /> c PUMP <br /> ❑Nofinstalled. 'Date installed _ . <br /> �+ <br /> 0 It rray .. Manufacturer's name , - , ' - <br /> Model number HP Votts. <br /> sand grill' 70t 13 Length of drop pipeSO .g C <br /> apex . • g.p:m. <br /> Type.'i Submersible. ❑L.S.Turbine ❑Reciprocating 0 Jet. ❑_. <br /> ABA!• ED WELLS <br /> Does property have,any'not in Use,and not sealed yyell(,$) 0 Ye.@No.,, <br /> VARIANCE - <br /> ' Was a variance;granted from the MDH for this welf2_,❑Yes, No TN# L ... <br /> ',WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and inraccordance with Minnesota Rules,Chapter 4725. <br /> The iidormation contained In'this report is true to the best'of my knowledge. ' <br /> Use a second sheet d needed . <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Stemma Drilling a Envirennental <br /> see Business Name Lic.or Reg.No. <br /> ,. 1� r .. - C)5 <br /> Authorized Representative Signature <br /> Date <br /> LOCAL COPY 715850 Name of Driller <br /> IC 140-0020 HE,01205=oe(Rev.5/02) <br />