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�_.\ \ WELL LOC ITA ON MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o��Y Name WELL AND BORING RECORD 6 5 5 0 9 6 y Minnesota Statutes Chapter 103/ t T�sCh�Na e� Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � tt. �, � House Number,Street Name, ity and Zip Code of We I ocation or Fire Number DRILLING METHOD $S�.lOt3 �r14L'�t� MariSd ❑ CableTool ❑ Driven ❑ 0�9 � � ❑ Auger �C7.Rotary i.7 Jetted - - Show exact location of wel�in section grid with aX". ,� Sketch map of well location. ❑ �� Showing property lines, ��- �� - roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �JIO N 'a i � � � � � .__..- Faonn _ _n.�o n. __ ___ ___ __ R �"�` � USE ❑ Monitoring ❑ Heating/Cooling i � i i ❑ Domestic -�- -�- -i- -�- ❑ Irrigation � Community PWS �7 Industry/Commercial i i i i � �Noncommunity PWS ❑ Remedial w I i e �� . ❑ Environ.Bore Hole ❑ Dewatering ❑ i , i r ,�'M � �` CASING Drive Shoe? es ❑ No HOLE DIAM. � _i_ _ i_ _L_ _i_ Z ��,�. � �Steel �Threaded ❑ Welded � � � � 1� ❑ Plastic ❑ S �-1Mrle� _ CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 4 in.to 259 n. I 1 Ibs./ft. 7 �if t6� tt. 0 Griggs Contractin �� o--___h __.___ �bs.�n. 3__T�� 5 Property owner's mailing address if diBerent than well location address indicated above. in,to ft. __Ibs./ft. in.to ft. -_-. a��n:Chancey Griggs SCREEN OPEN HOLE 530 Shoreview Park Rd Make from K.�o K. ' Shorevie�r, MN 5512b Type Diam. SbUGauze __ Length___. Set between ft.and ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME yv ft.�'below ❑ above land surtace Date measured� PUdAP�LEVEL(below land surface) t c Well owner's mailing address if different than property owner's address indicated above. 1 _____ft. after_ v hrs.pumping 3 J g.p.m. WELL HEAD COMPLETION t �Pitless adapter manufacturer W�1�e��t @� Model _____________ ❑ Casing Protection ,y�12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) �i GROUTING INFORMATION Well grouted? f�Yes G No � HARDNESS OF Grq�t M eri f l Neat r^—,� ❑ gento{'it�y � Concr te ❑ High Solids Ben[onite GEOLOGICALMATERIALS COLOR MATERIAL FROM TO VOLC�S� from_�� to 17�ft. ��______ ❑ yds.�bags cement from 19Q to��ft ZQ___ ❑ yds.�bags ° •- f i 1�, �p $fl f from___ ______to. ft. ❑ yds. ❑ bags ; NEAREST KNOWN SOURCE OF CONTAMINATION �.'�8 /fine sand t$ $Q f �.o--�Qet __direction inside type Well disinfected upon completion? �Ves � No �Iumbing (,`I8 ra r.��f PUMP �- ❑ Not installed Date installed _...4�+_�.�,..�� � i$ Jfine sand r$ � Manufacturer'sname _��']�.Ot.Dl^_..... ..._ ._.__ Model number __ . .. .. . _. _ _. HP ��n f __�__ ,_._ Volts ' ravel/cobbles brow� Lengthofdroppipe _V`�___________ h Capacity _ g.p.m. Type: �Submersible r7 LS.Turbine ❑ Reciprocating ❑ Jet ❑ la L OWC� S ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �No ra0e2�C1$ r VARIANCE � 7 r�Wn/ Was a variance granted from the MDN for this well? �Yes �J No TNri : .:i� �� 2a fine sa WELL CONTRACTOR CERTIFICATION lt �reen a e ond s et� needed 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. 'F REMARKS,ELEVATION,SOURCE OF DATA,etc. ' andstone brown hard 259 275 Dan_Stodola Well_ Drilling G�. . ��t�__ 172 ` ;,, �� Lic nse usiness Na -� f Li �Reg. o. � .'-' i �: „�r.��- 5'`7.'"�1 , � , uNio1'iz Represen ive ignature —^'' Date Duane Aiathews 4-6—pI _ ____ _ --_. - ___--- . 6 5 5 0 9 6 Name olOriller Date LOCAL COPY HE-01205-07(Rev.2/99)