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MINNESOTA UNIQUE WEL"L �L�30!�I�LOCATION MINNESOTA DEPARTMENT OF HEA�TH AND BOR/NG NO. �o„�,y N�,�� WELL AND BORING RECORD � � �� Minnesota StaWtes,Chapter 1037 � Township Name Township No. Range No. Section No. Fraction WELVBORING DEPTH(completed) DATE WORK COMPLETED �� fl. �=. GPS DRILLING METHOD �- LOCATION: Latitude degrees minutes seconds ; ❑Cable Tool Longitude degrees minutes seconds ❑Driven ❑Dug ❑Auger �Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No � Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. ��t�te From ft.To ft. Showing property lines, N roads,buildings,and direction. USE �Domestic �_Monitoring ❑Heating/Cooling ; � � � � �. >. __J____1__ ___�____L__ "� ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial � ❑Community PWS �Irrigation ❑Remedial --1------;-- ---F-----t-- �]Elevator ❑Dewatering ❑ ' 1 �' , , , ; E T �ti CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. ' --+-- --�-- --F—---<-- - � I �: [j Steel ;]Threaded ❑Welded ` ' � ' � Mile StIC i� , , � Pla ❑ ; --�--- --�-----�----�- t ,,,. � I ; ' ' � CASING �S ;' S � Diameter Weight Specifications [�N e �n �—1 Mile� '* in.to 1a�_ft. �i9 Ibs./ft. �� in.to .7V ft. e � Q a PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.to�j�ft. in.to ft. Ibs./ft. in.to ft. Property owner's mailing address if difterent than well location address indicated above. SCREEN OPEN HOLE - AL �+f�_� n�7 Make � ��,t.,. * From ft. To ft. 21P�f .71i�1� iU,i Type $iPil[1Z�.'�s Sti Diam. �trj� E'II7 SS�� Sbt/Gauze�_rn� Length �� l� �}�� z Set between ft.and ft. FITTINGS � STATIC WATER LEVEL � Measured from ft. elow ;]Above land surface Date measured � � WELL OWNER'S NAMEJCOMPANY NAME PUMPING LEVEL(below land surface) ' !v� ft.after �� hrs.pumping 25 g.p.m. �' Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �� -1� - � F ��Pitless/adaptermanufacturer iJ.�'I -�-��`��fl"�'�Idd�f ❑Casing Protection �712 in.above grade ❑At-grade(Environmental Well and Boring ONLY) ��` GROUTING INFORMAT ON Well grouted �Yes ❑No Grout materials J Neat cement�Bentonite ❑Concrete ❑Other From_�To�' ._ft. � i]Yds. �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From '�__To�.g'�_ft. �_�'r�. ❑Bags MATERIAL From To ft. ❑Yds. ❑Bags 1.� NEAREST KNOWN SOURCE OF CONTAMINATION CJ.iTy Il� �Lt � l� �'-" :J feet �.,ti _,—_direction ^d� ��.-:�-:^"-s�-..rrype Well disinfected upon completion? ' Yes ❑No . ;..,,,;,,,,,,, t � �..,j,� clay ray - soft I6 b3 PUMP / c L ❑Not installed Date installed ! � � � � $��t �� i� G� �� Manufacturer'sname ��-.�—`+�--'`�✓"�'ti��`"�'+"�-- Model Number HP /�Volts ciay ropn sofr iS0 180 � Length of drop pipe �J v ft. Capacity g.p.m. 3CiilCl � �ft 4$A 1 A5 Type: Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ 1 V 17 ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION s 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,il needed. REMARKS,E�EVATION,SOURCE OF DATA,etc. �1 ,S'toc�ola Well Drillir.� Co• ��• ZU7� Licensee Business Nam � Lic.or Reg.No. � ' ... ! h .�1r"✓� ? - C resentative Signat re Certified Rep.No. Date F � ' � �O�` � Name ot Driller � �re , LOCALCOPY IC 140-0020 HE-01205-10(Rev.6/O6)