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r,nmrnrccn-re r rnunr rc urcr ~ <br /> WELL OR BORING LOCATION <br />- MINNESOTA DEPARTMENT OF HEALTH AND BORING ND. <br /> ~ <br />C <br />f <br />N WELL AND BORING RECORD - <br /> ame , <br />oun <br />y 7 <br />~ <br />~ <br />~ <br />~ <br /> ~ ~ Minnesota Statutes, Chapter 1031 ~,) <br />n <br />j <br /> Township Name. ~ Township tJo. Range No. Section No. Fraction WEL'v'BORING DEPTH !completed) DATE WORK COMPLETED <br /> ou <br />CC~~ <br />~~ <br />nn ~ , <br /> _ <br />~~ <br />..,, <br />~~ <br />.. <br /> GPS <br />LOCATION: Latitude degrees minutes seconds _ DRILLING METHOD <br /> <br />~~able Tool ^ Driven I; Dug <br />~~, <br /> Longitude _ degrees _ minutes seconds ~ <br />uger (]Rotary ( <br />Jetted <br /> House Number Street Namz, City, and Zip Code of Well Location or Fire Number.- t ~ ~ <br />'7/ _, <br />r <br /> ~ <br />~ <br /> . <br />~~ Y <br />=' ; ~ ~ J L« C,i S '~ (7 ~` ~ ~' ~~~-X...t~) Yt'l tl DRILLING FLUID WELL HYCROFRACTURED? ^ Yes ~No <br /> Show exact location of well boring in section grid •Nith'X' Sketch map of well/boring location. <br />Showing property lines ~Gi n ~ F rom ft. To ft. <br />, <br />` <br />'~ {~ roads <br />buildings <br />and direction. <br />USE <br />, <br />, <br />tl ^ Domestic ~ i lonitoring ^ Heating/Cooling <br />I ~ ~ ~ ^ Noncommunity PWS ^ Environ. Bore Hole ^ Industry/Commercial <br />i~ , 1 5 C ~ p.~~ ~ <br />"1 ^ Community PWS ^ Irrigation ^ Remedial <br />__~___ _-~_-. __;-- ___j-- [_I Elevator ^ Dewaterin9 [~ _ <br />w <br />"''"- <br />--'--- <br />--~-- <br />-'"'" E <br />T ?~ ~ <br />~ <br />~~ 3 ~~ ~ <br />`'' CASING MATERIAL Driv Shce? ^ Yes No <br />I <br />~ OLE DIAM. <br /> `.3 <br />t <br />w [. <br />Steel hreaded [, <br />Welded <br /> Plastic [ j <br />1 <br />~ ~ CASING <br />S Diameter Weighs Specifications <br /> <br />` e <br />i <br />f <br />'~ <br />~ ~ <br />t <br />1 7 <br />~ <br />~ <br />r i Mile ~ n. <br />_ <br />0 <br />ft. _ lbs./ <br />t. <br />-- <br />_ in. f0_ <br />ll. <br /> <br />PROPERTY OWNER'S NAMEICOMPANY NAME ~ in. to - ft. __ lbs./ft. in. to ft. <br />(I / f 1.., _ ~ <br />~ <br />t <br />~ <br />~ <br />~ _ in. to ft. _Ibs./fL _ in. to ft. <br />v <br />~ <br />` <br />J I %~ (~- <br />'' <br />~ OPEN HOLE <br />rs mailing addr'aSS if differenLthan well location address indicated>~ve. <br />Prope <br />rty owne SCREEN_r __ <br />I C ~ n <br />`` <br />C <br />!~ <br />y <br />l <br />~J ~ `-4~ l;••_~ <br />i,i ~ ~: ~ _ ~ . <br />. <br />• <br />Make .. <br />r„ - From ft To ft. <br />- <br />a <br />`j Slot/Gauze __ y ~ _ _ _ Len th U _ _ <br />~ <br />l G `~T <br />~ ~ <br />~ % ~ O / 1 <br /> ~ <br />Set between <br />ft. and <br />ft- FITTINGS <br /> STATIC WATER LEVEL <br />Measured from <br /> ~ <br />' J <br />'~7 =~ _ft.! elow ~~ Above land surface Date measured ~ -~~ <br />WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL (below land surface) <br />~J ~ ~ "r ~"(_,. _f[. after hrs. pumping----_ g.p.m. <br />Welllboring owners mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> 1 _l dless/adapter manufacturer- _ o el_-__ __ <br />~ r r C) <br />t <br />, <br />~ <br /> _ <br />Casing Protection-_ <br />L <br />~ <br />2 in. above grade <br /> ^ At-grade (Environmental Well and Boring ONLY] <br /> GROUTING INFORMAT, IpN <br /> Well grouted es ^ No <br /> Grout materials Neat cement ^ Bentonite (1 Concrete ^ Other-_- <br /> - <br />From_3 ~ To ~ ft. - ~ __ [) Yds. (J`1 gags <br /> <br />GEOLOGICAL MATERIALS COLOR HARDNESS OF <br />MATERIAL FROM TO From To ft. ___-_-_ [_i Yds. ^ Bags <br /> From To ft. _, (_J Yds. ^ Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br />~. (~ <br />_~ . _ -feet direction _____ type <br /> <br /> Well disinfected upon completion? ^ Yes ~o <br /> PUMP <br /> ~~lot installed Date installed - <br /> Manufacturer's name <br /> Model Number ___ __ HP _ Volts__ <br /> f d <br />L <br />th <br />i <br />ft <br />C <br /> rop p <br />eng <br />o <br />pe--- _ <br />. <br />apacity-,--- g.p.m. <br /> Type: iJ Submersible ^ L.S. Turbine ^ Reciprocating ^ Jet ^ ___ _ <br /> ABANDONED WELLS <br /> <br /> <br /> Dces property have any not in use and not sealed well(s)? ^ Yes (~No <br /> VARIANCE <br /> <br /> <br /> Was a variance granted from the MDH for this well? ^ Yes ~o TNiF <br /> CONTRAC <br />T <br />IC <br />T <br /> WELL <br />TOR CER <br />IF <br />A <br />ION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules, Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br />Use a second sheet, it needed. <br />REMARKS, ELEVATION: SOURCE OF DATA, etc. , ~ ;-~ ~ r /' ~7 ,/ - <br />' <br />f <br />4 <br /> >~,.t:~ <br />(~ r C_ ~ ~ tr + L ' i f (l <br />ti~ I ~ 7 % t~ <br />~-"~ :.-~.~ <br />J1 / Licensee Business Name ic. or Reg. No. <br /> ~ ~~ <br />/( <br /> _ <br />ifi <br />7R <br />~- <br />i <br />Si <br />C <br /> ert <br />et <br />epres <br />entat <br />ve <br />gnature Certified Rep. No. Dale <br /> <br />I~FORTAh!7 -FILE':^~'!TH F°OPERTY PAPERS / r" ~] <br />~ ~ <br />~ l ~` `'C~~ ~µ 1-~•>--- ~_..~ _ _ ~~( ~ ~" 'y <br />---------- - <br />- <br />'`JELL OVvNER COPY f ~ <br />1 Name of Driller <br />-- <br />------- ----------I <br />IC 140-0020 r+t~olzos-1o rq=., 6roe) <br />