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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH • ~~AND BORING NO~ ~` <br /> County Name WELL AND BORING RECORD <br /> <br />v~~~Q~ <br />Minnesota Statutes, Chapter Y037 7 5 5 5 7 2 <br /> Township Name ~.vnship No. Range No. Section No. Fraction WELL/BORING DEPTH (completed) DATE WORK COMPLETED <br /> ~~ L: ~.~ 3 ~ ~, 3 =~~ ~~ . ~ ~~ ~~ h c~ a - ~ ~ <br /> GPS <br />LOCATION: Latitude degrees _____ minutes seconds DRILLING METHOD <br /> <br />~ able Tool [] Driven ^ Dug <br /> Longitude degrees minutes seconds [Auger ^ Rotary ^ Jetted <br /> House Numb <br />e <br />r, Street Name, City, and Zip Code of Well Location or Fire Num <br />be <br />r ~; <br /> C <br />~ <br />~FlE' <br />) <br />~ ' <br />~ 1 ~ ~ <br />~~ <br />1 <br />~~~ ~ <br />j <br />^~ <br />~ <br />~J~ <br />~ <br />'~ DRILLING FLUID WELL HYDROFRACTURED? y Yes ^ No <br /> 5 <br />.3~-~ <br />i <br />t,y;~..Y~2.L. <br />- <br />1 , <br />/ <br />o <br /> <br />Show exact location of well boring in section grid whh "X'~ Sketch map of wellJboring location. <br />Showing property lines l <br />ti, Ja ~ .~ F <br />rom R To y- <br />, <br />N t roads, buildings, and direction. <br />USE -- <br />^Domestic onitoting a Heating/Cooling <br />' <br />....._ _~_ _.....__.__ oncommu S nwron re Hole ~ ~ In <br />^ N nity PVJ ^ E . Bo _ dustry/Commercial <br />~„~ ~ ~ ~ `~ , ~ ^ Community PWS ^ Irrigation ~ ]Remedial <br />--i--- --'--- ---;-- ---!- [j Elevator Dewatering [~ _ <br />w <br />_ __ <br /> <br />-'~ <br />_ __ <br /> <br />- <br />- <br />__ __ <br /> <br />-` <br />_ __ E <br />T ~ u + ~„ ~ <br />~ • 4-• ~ ~ <br />\ ~ <br />~ ASING MATERIAL ve Shoe? ~o <br /> <br />Dri es _ <br />C ^ Y HOLE DIAM. <br /> ' <br />' `-^/ ^ Steel I~Threaded [ J Welded <br /> 1 I I <br /> <br />: h Mife lastiC n <br />~P <br />_ 1 <br />. <br />--~-- --T-- ---~- --- <br />~ <br />CASING <br />s Diameter Weight Specifications <br /> <br />», (- t Mile ~ <br />_ ^J _ ::" . r i! ~- <br />in. to ~ tt. Ibslfi. ~ <br />O in, to ~t "ft. <br /> <br /> <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />~~ in. to 1l. lbs.ltt. <br />--- - - in. to tt. <br />~-`) <br />S <br />~~~ ~ _ S~ <br />" <br />` in. to tt. lbs./h. _ <br />in. to tt. <br />l <br />\"R }"} <br />t a OPEN HOLE <br />Property owner's mailin ddress it different than well location address indicated above. SCREEN~_ __. _____ <br />" <br />1 <br />!% C; ~ <br />~ ~ <br />~ <br />~ <br />~ ~~ '`~ <br />-- ~ <br />~ -i Make J . 1-~i1S c r'~ From <br />ft. To ft. <br />' ` <br />V: <br />.. <br />,~ <br />C <br />~ <br />V <br />~ <br />1~{~ ~~ ~ ~ ~ ~- ~ / <br />1~' V/ <br />~ ~` e <br />` <br />' <br />C SIoUGauze - f O _ .Length 1 ~ - - <br />3 <br />t <br />~ ~ <br />" <br />- <br />: <br />V <br />,~ 1 l <br />r Set between <br />~ ft. and <br />" <br />_ ft. FITTINGS 1 <br />1 +a .i hJi ~ r ~ "t <br /> STATIC WATER LEVEL <br />Measured hom___ <br /> _ <br />~~ ft. Below [] Above land sudace Date measured ~ 05 - (~~ <br />WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL (below land surface) <br />~~ <br />x ~~ <br />~ <br />- <br />-~ _tt. after hrs. pumping- m. <br />9P <br />WellJboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer <br />Model <br /> Casing Protection ~ ~ t rV ~n ~ __ '~fj/72 in, above grade <br />_ <br /> (] At-grade (Environmental Well and Boring ONLY) <br /> GROUTING INFORMATtOj~l <br /> Well grouted es ^ No <br /> Grout materials Neat cement [ j Bentonite ~] Concrete I ~ Other______ <br /> From .~ i_ To O tt. (G ^ Yds. ~ags <br />GEOLOGICAL MATERIALS COLOR HARDNESS OF <br />MATERIAL FROM TO From To h. ^ Yds. ^ Bags <br /> From To__._ ft. _ ^ Yds. ^ Bags <br /> NEAREST KNOWN SOURCE OF CONTAIvtINATION <br /> <br />i~-~ ~ <br />r <br />~~ <br />~ ~ fd° <br />_ __ feet direction <br />type <br /> - <br /> Well disinfected upon completion? ^ Yes No <br /> PUMP <br /> (Not installed Date installed ._ _ <br /> Manufacturer's name <br /> <br /> Model Number__ HP_ Volis____ <br /> <br /> Length of drop pipe- fi. Capacity ___ g.p.m. <br /> Type: [] Submersible [] L.S. Turbine ^ Reciprocating [] Jet ~! __ <br /> ABANDONED WELLS <br /> <br /> Does property have any not in use and not sealed well(s)? ^ Yes No <br /> VARIANCE <br /> <br /> Was a variance granted from the MDH for this well? ~,] Yes No TfJ#__ _ <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my super•dision and in accordance with Minnesota Rules, Chapl2r 4725. <br /> The information contained in this report is true to the best of my knowledge. <br />Use a seco nd sheet, it needed. <br />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br /> - <br /> Licensee Business Name T <br />Lic. or Reg. No. <br /> <br /> ~f3~f1', i ~ ~I!~'= <br />' rtifi <br />d•R <br />ti <br />Si <br />t <br />C <br /> - <br />epresenta <br />e <br />ve <br />gna <br />ure <br />ertified Rep. No. Date <br /> %.' <br />ibl!POR i ANT -FILE +'t'iTH Pi:OPERTY PAPERS ~j 7 <br />~ ~ ~ <br />~ ~ I~ ~ r <br />~I~ / ~` ~i _~~ <br />~~ ~ ~ y <br />, ~' <br />'vY`ELL OVdNEP. COPY v r _ __ _ <br />_ <br />Name of Driller <br />Y <br />IC 140-0020 faE-ot2G5-to (Rev c:06) <br />