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�, WELL LOC�TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o�-�Name WELL AND BORING RECORD 6 4 9 2 2 3 Minnesota Statutes Chapter 103! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed fl /. /. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD ❑ Cable Tool ❑ Driven ❑ Dug Cl Auger �Rotary ❑ Jetted - Show exact location of well in section grid with' ". Sketch map of well location. fl _ � Showing property lines, .0 � �n L /�N� ��ds and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑VES �'NO N �..� L. L' , , , , FaoM__ n.�o n. -; -;- -r- -,- USE ❑ Monitoring ❑ Heating/Cooling i i � i �Domestic � _i_ _�_ _�_ _i_ ❑ Irrigation � Community PWS ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w e T ❑ Environ.Bore Hole i i i � Cl Dewatering ❑ ' i i i 'ZIM,1e CASING Drive Shoe? y�f Yes ❑ No HOLE DIAM. _i _�_ _1_ _�_ I .�'Steel fd'Threaded — ❑ Welded ' ' ' ' 1 ,.❑ Plastic ❑ S �-1 Mile-{ �G CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � in.to_!9� n. 11 ___ibs./ft 7 ��08 �(� ____. in.to ._ft. _IbsJft. �in.to�tA Property owner's m i address if different than well location address indicated above. —.—____.—in.to _ft. Ibs./ft. �__�� SCREEN OPEN HOLE Make from ft.to_ ft. $��e �e� above Type Diam. ____ ____ (CARSIAGS HOUSE) Sbt/Gauze Length___ __ Set between R.and ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME ��o_ _ft.�below ❑ above land surface Date measured 7�� PUMPIt�G�F,�EI(below land surface) � �O Well owner's mailing address if different than property owner's a dress indicated above. _� U _ft. atter hrs.pumping g.p.m. WELL HEAD COMPLETION �Pitless adapter manu�acturer Nhi��NB�e r Model _____ ❑ Casing Protection _ _ �'12 in.above grade Cl At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION - Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete �High Solids Bentonite MATERIAL from_._�_to__'�_ft. __�T� ❑ yds.�bags � t trom_�_ to�_p�.—tt.na t��„8� �df. ❑ bags C18y ye110W .gOft � l� trom______toi�u_n. _ � Yd� ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION 1} /T�` t. ( f ryPe C1'$37 gray 3�ft 1$ 5� �------feet ��l�.r�___direction S-� �ray Well disinfected upon completion? J�!Yes ❑ No claylgravel white aoft 52 6$ PUMP ❑ Not installed Date installed. _��_2_�_.Q�_, SBndY �lay gray 801 t 6� �� Manufacturer's name _._�Qyy�___.___. _ __ o Modelnumber _____ _.__..._ _ _ HP ��_ Volts f�.7� ��8 C�ray� $��t oo �� Length of drop pipe _. ��._ ______ ft. Capacity __._, g.p.m. Type:�'Submersible I7 LS.Turbine ❑ Reciprocating ❑ Jet ❑ � sand /cla �ra soft 115 140 ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �'No _ cla /sand broWn soft 14U 170 VARIANCE Was a variance granted trom the MDH for this well? f] Yes �YNo TN# cla /sand ra edium 170 181 WELL CONTRACTOR CERTIFICATION $8�Qd�'eUse a second��e�ded hard 1 O1 21� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The information contained in this report is true to the best of my knowledge. � �"" -��e�rfle�..._��. . ic. ef.1'o. 1[i4• G 172 � ,....--�---' �� - --- ----- Z�Z_� � -. Authorized Representahve Signature Date ----- _-��aII��i8��levi�_- 7"1.2�2_ 6 4 9 2 2 3 Name ol Driller Date LOCAL GOPY HE-07205-07(Rev.?J99)