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MINNESOTA UNIQUE WELL f WE�L�fBORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name � WELL AND BORING RECORD 7 3 917 5 �p�� Minnesota Statutes,Chapter 103I Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED 4tu[�o I18 23 36 ,i, ,�, ,i, I49 n &-31—Ofi GPS DRILLING METHOD Latitude de rees minutes seconds A LOCATION: 9 - !:Cable Tool I I Driven ❑Dug Longitude degrees_ minutes seconds I��.Auger �otary f_!Jetted � House Number,Street Name,City,and Zip Code of Well Location or Fire Number � 35t} Rciac�n Rd, vLCAlV SJ�l DRILLINGFWID WELLHYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X." lt_. Sketch map of well location. �Zt�lt� From fl.To ft. �T Showing property lines, N roads,buildings, USE i omestic �. I Monitoring L I Heating/Cooling '��; � ; � ; � and direction. � � �Y � I Industry/Commercial �� �' --'-----'--- --`-----'-- � : . �: oncommunit PW . Environ.Bore Hole "�:Commundy PWS '�� I Irrigation '�. I Remedial � I !Elevator I 1 Dewatering �' --'-�---'--- --'--- ---�-- � CASING MATERIAL Drive Shoe? ��Yes � o HOLE DIAM. ' '•�� W � � � � E hreaded Welded ,. , , , , �,M _ _ C 7 Steel '1 T ' --�--- � --'--- '—�-- --'— �: �Plastic - y� �e �',' --�--- --'---—�-- ---'-- CASING '�.: 3 � Diameter -�- Weight Specifications 5 � � S � � 4 140 2.li astm 8 3fl �1 Mile� �� in.to ft. _ IbsJft. __ �y in.to ft. � in.to .. . _.__ft. Ibs./R "i in.to�ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. � �� SCREEN i..t..._.�...... OPEN HOLE �t, �[7i7�[I—"- Property owner's mailing address if different than well location address indicated above. Make From t.To ft. � � BWYC TYPe . Diam. ..__ _ � Slot/Gauze ��_� Length ___,—v_�� . Set between ft,and FITTINGS 2� >� STAT�INATERLEVEL �� 6_�� , `77 ft.�Below �. I Above land surface Date measured �l _. _ . PUMPING LEVEL(below land surface) WELUBORING OWNER'S NAME/COMPANY NAME �� ft.after_ 2 hrs.pumping_ � g.p.m. L HEAD COMPLETION t ��Q � � �n� Well/boring owner's mailing address if different than property owner's address indicated above. �tless Adapter Manufacturer �.+�'"""'--'�"'�'—Model._____ � I Casing Protection �.12 in.above grade _7 At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted? �Yes ❑No Grout materials 1.7 Neat cement�Bentonite '� �.Concrete I �.Other_ � From _a_To.�_ft. � ��!Yds. �Bags From�' To��ft. �� I�'�d� ��Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. I I Yds. I i Bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION topspfl black �ft t3 4 �'=� `.' � �.:��" �; :._''". ' feet direction `fype Well disinfected upon completion? Yes �I No -. � �tL�l U� �ft 'T �� PU oPinstalled Date installed �" ' -� �� CI$v g�$y �s•t �fE 1 1£ Manufacturer's name_�"J �`-'`�'�� ! i �R LiJ (�� -}�� Model Number HP � � Volts ly �iDLL��r��l �$y a�it 11� Zy9 Length of drop pipe r O�`� ft. Capacity g.p.m. Type: ubmersible _]LS.Turbine I._'�:Reciprocating i.I Jet ��. I ABANDONED WELLS Does property have any not in use and not sealed well(s)? L-Yes �� o VAAIANCE � Was a variance granted from the MDH for this well? -Yes ��o TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. - �� REMARKS,ELEVATION,SOURCE OF DATA,etc. � SL�1S �Ci� �ZI1I� 4V�� ILICs 1�� —� -- -------- -- ---- Licensee Business Name - Lic.or Reg.No. .__- - /G _,.��_�� ; ; � - 1 -- � Y�Cd e fes ntative Sig��u Date Ctxick Moore 7 3 9�7 5 Name ot Driller LOCAL CG�`r ` HE-01205-09(Rev.9/05) ic iao-oozo