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WELL LOCA fiiyN MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> ' Count�Name };. ^, ; WELL AND BORING RECORD � � g � � �
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<br /> Minnesota Statutes Chapter 103/
<br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
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<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD �
<br /> _ . _ _ ,`.�� � � .. .. _,.,--� •. _. �..�7 .....�: � .,. . _ . „ ';t j ❑ Cable Tool ❑ Driven ❑ Dug
<br /> ❑ Auger ❑ Rotary ❑ Jetted
<br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _
<br /> Showing property lines,
<br /> ; roads and buildings. DRILLING FLUID
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<br /> �_ -�- -�- -� ' f; -�` ' USE ❑ Monitorin
<br /> i i i � .C7 Domestic 9 ❑ Heating/Cooling
<br /> _i_ _�_ _�_ _i_ ❑ Irrigation � Community PWS ❑ Industry/Commercial
<br /> i i i i �, ❑ Noncommuniry PWS ❑ Remedial
<br /> w I ' E T . ❑ Test Well ❑ Dewatering ❑
<br /> i i i _r +�ZIM1e � CASING Drive Shoe? O.>Yes ❑ No HOLE DIAM.
<br /> ����. i_ _�_ L_ i_ � ��---"- -�-� �fJ Steel ❑ Threaded ❑ Welded '
<br /> -� � -� _� '�� ❑ Plastic �
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<br /> �1Mile� I . t , .. .� j ;. ..
<br /> ''���� i�'`' �� � CASING DIAMETER WEIGHT
<br /> PROPERTY OWNER'S NAME �• � ":r � ' `
<br /> - :f. . . . i'i_-. ..=� E. .. _,. �4��1:w. . t_�
<br /> in.to ft. Ibs./ft. in'to �ft.
<br /> in.to ft. Ibs./tt. in.to ft.
<br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./tt. in.to_R.
<br /> . ,! � , r t �;' t �� . SCREEN OPEN HOLE
<br /> ...,:�..:c. . ' �, -� � _ .. .. .. . Make k � i.` ��a. from ft.to ft. -
<br /> TYPe i 1 F`:1 E.'.`- i - .� Diam.
<br /> SIoUGauze l ,% � ` length +;
<br /> Set between '�,�.;`- ft.and_�_•,�3t. FITTINGS: r �� 3: +"'/�;� e
<br /> STATIC WATER LEVEL
<br /> ' WELL OWNER'S NAME i } ' ft. G3.below ❑above�and surtace Date measured i ' - - - �'-'
<br /> PUMPING LEVEL(below land surface) ��
<br /> Well owner s mailing address if different than property owner's address indicated above. R. after hrs.pumping � ����' ���g.p.m.
<br /> WELL HEAD COMPLETION
<br /> ❑.F>itless adapter manufacturer -'� � "�`� �" �� Model
<br /> a ❑ Casing Protection �J 12 in.above grade
<br /> ❑ At-grade(Environmental Wells and Borings ONLY)
<br /> t GROUTING INFORMATION
<br /> Well grouted? �❑ Yes ❑ No
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite_.O Concrete Q;High Solids Bentonite
<br /> MATERIAL from ro ' `it. ❑ yds.� bags
<br /> j 1 r�,t , x from to ft. ❑ yds. ❑ bags
<br /> - � from to tt. ❑ yds. ❑ bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION ...
<br /> ,_�; . ,"i'- - f� , � �.:r � feet '�. direction !' v'� M,h'Pe
<br /> Well disinfected upon completion? Q�.Yes ❑ No
<br /> 1.� . . � .,. 7�w:. .`7 l ..:f' 1_.�. PUMP I � � ^ . r
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<br /> ' O Not installed Date i�4all�d -
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<br /> � Y�++ � � -��� ` ,;-,�;. ' Manufacturefs name . _
<br /> . � _'i'�; / f::_..... . ..-.'.S_ ' �:`.;i i�: � __ . . .. � . :'. ._ ..
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<br /> Model number t � u ' HP � Volts ' `
<br /> Length of drop pipe �� ft. Capacity �- g.p.m.
<br /> Pressure Tank Capaciry _L'l_ ! �'
<br /> Type: O.Submersible O LS.Turbine ❑ Reciprocating ❑ Jet ❑
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? ❑ Yes L`I�1�0
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ❑ Yes [],No
<br /> WELL CONTRACTOR CERTIFICATION
<br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etC. The information contained in this report is true to the best of my knowledge.
<br /> ��VE�V�v l . . i;t : ; .'.� I ,_ , . _. . ,. , ,
<br /> Licensee Bus�ness Name � Lic.or Reg.No. , „ ,
<br /> �EB 2 01997 ;j �'� �--���`,-. 4 !- _ V . i �;..
<br /> �`� Authorized Representahve Sgnature Date
<br /> �I r��C�ORONO . ,
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<br /> �..- �, ,� Nameo/Driller Date
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<br /> HE-01205-OS(Rev.t/95)
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