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� . . � WELL��OCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. '. CountyName WELL AND BORING RECORD . � $ � 4 �` 5 ��SnE��1n Minnesota Statutes Chapter 703/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. c.�rc�ri�� i 1 i 2 i 11 ,�, ,. �. �`_%;J' 6--�-�6 House Number,Street Name,City,and Zip Code of Well�ocation or Fire Number DRILLING METHOD �4��7 ��C)I E.'.�111� DT1.V� �Ci7�t� �1.��.'4��-.1 ❑ Cable Tool ❑ Driven ❑ Dug t � � ❑ Auger LSJ�Rotary O Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ C Showing property lines, � roads and buildings. DRILLING FLUID N �,J �C'.]'i�C?T11L_� _i i i �_ � `�l _ ___ ___ _ � USE ❑ Monitoring ❑ Heating/Cooling i i i i y � �Comestic ❑ Community PWS ❑ Industry/Commercial _i_ _�_ _i_ _i_ }� � Irrigation � � � � � ❑ Test Well � Noncommunity PWS ❑ Remedial W ET i i i \,; ❑ Dewatering ❑ -r -�- -r- -r j i i i � - � '/ZM,e ;� �' ] CASING Dnve Shce? ❑ Yes ❑ No HOLE DIAM. _�_ _ i_ „� ❑ Steel ❑ Threaded ❑ Welded -L- -�- � � —r...� i i i i i � OX?lastic ❑ s �--1 Mile-� CASING D.�AMETER WEIGHTc ^� La �ti� +.7�.c.1 ! ��FCt. �E.: PROPERTY OWNER'S NAME in.to ft. Ibs.ttt. in.to ft. �G�1�= �1i'�li.;(iZ; �t t'S£'`,c.tC..1::t:�S in.to ft. Ibs./ft. +� t�,t f—f'`�,i�?`•� �l �[ Property owner's mailing address if different than well location address indicated above. in.to ft. ibs./ft. _in.to_tt. SCREEN OPEN HOLE ��% �n{':Y�'1'3�`rBr1'�7� Make �C?�lll-.��C'?��1 from ft.to R. �ic3�'Zc�Lc�� 1. �_,:�i� C;-- TYPe_ -��y�7 t11 Eu;c% r-...€�P� Diam. SIoUGauze '�.(1!1 t� Length ' Set between �is� ft.and ��.i: fl. FITTINGS: STATIC WATER LEVEL 1 WELL OWNER'S NAME �i� ft. DKbelow ❑ above land surface Date measured -�� PUMPING LEVEL(below land surtace) Well owner's mailing address if different than property owner's address indicated above. ��`N ft. after_ � hrs.pumping g.p.m. WELL HEAD COMPLETION �;pitless adapter manufacturer f!�'fl f.��9j`_E�Y Model ❑ Casing Protection C�12 in.above grade � ❑ At-grade(Environmental Wells and Borings ONLY) � GROUTING INFORMATION Well grouted? �iYes ❑ No HARDNESS OF Grout Material O Neat cement entonite ❑ Concrete ❑ High Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ., from L� � -S�' ft. R= ❑ yds. C�bags ��r`�J �E'��„ti.�M1 .�.j !,i 7(° from -SL7 to�r'r`f�. ��7 Yds. ❑ bags from to ft. ❑ yds. ❑ bags NEARES <NOWN SOURCE OF CONT INATION � �7'� G�.d�-��sJ-'��E� �irE'�' : 1z�.t �;e � feet �/'r��/ direction type Well disinfected upan comp�etion? ❑ Ves ❑ No �-- � L"��" c'��Y1C: `��'3� :.� �?�� `.'�i PUMP ��-„�� ❑ Not installed Date in�lle� Manufacturers name �x j `'� Modelnumber �'��' � % 4 HP � Volts L-l' Length of drop pipe �� ft. Capacity �� g.p.m. Pressure Tank Capaciry ��TI^� �%�� Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes LI?alo VARIANCE Was a variance granted trom the MDH for this well? ❑ Yes �Jo - WELL CONTRACTOR CERTIFICATION .f Use a second sheet,ilneeded 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 ot my knowledge. �tECE11�E� �.:� ��x::�, �.�:��r� r�rut��r� c�:��., ar�c. <;��;s: Licensee Business Name Lic.or Reg.No. FEB 2 Q 1997 ,. �._ �. �-�-Q� ,�' ;/�� _;�-�� � Authorized Representahve Srgnature Date CtTY OF ORO�O 1's•L-�: Leiby t�w�-•;�, � p� �,.5 �, � f, r..-. Name ol Driller Date ry:, � °'� � ' ' � b`' � - ` HE-01205-OS(Rev.1/95)