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•-,�,'�'�� ,� ..� ' t k'-�q� MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. - WELL LOCATION � � ��,<,��Vame WELL AND BORING RECORD Henne in ti��, , _ ,,,;;;��vs Minnesota Statutes Chapter 103/ 5 910 8 2 - Township Name Township No. Range Na Section No. Fraction WELL DEPTH(completed) Date Work Completed rc L�n La?ce 1 I$ 2 3 �� • �� ��Number et me,C ,and Zi C de of Well Loca6on or Fire Number DRILLING METHOD � J y�� ❑ Cable Tool ❑ Driven ❑ Dug � �'- . ❑ Auger f}Rotary ❑ Jetted Show exact loca6on of well in section grid v�"- ' Sketch map of well location. ❑ 11 _____ _ _ �,,,,J Showing property lines, roads and buildings. DRILLING FLUID N � �entonit� � � � � � _�- ' � � _�- -�� USE C] Moni�orin i � � i ':;` }t❑ Domestic 9 ❑ Heating/Cooling -�- -�- -�- -�- t ❑ Irrigation O Community PWS ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w i l e� � ❑ Test Well ❑ Dewatering ❑ _ - ' , r i '/zM e . -�+ CASING Drive Shoe? ❑ Yes}�❑ No HOLE DIAM. _� � _L_ _�_ I � ❑ Steel ❑ Threaded ❑ Weltled � �- � � 1 � ,X�1/ � Plastic ❑ �1 il� S ��, b �-,M.,a-� �.� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME ,4 _�_ in.to 1 �z R. �_i� Ibs./ft. in.to317 n. _ Spr�nC� H�1� Golf CLL�� ___in.to______tt. __________._. Ibs./tt. ! in.toZ��it. Property owner's mailing address i�different than well location address indicated above. in.to ft. __ Ibs./ft. in.to fl. �St.c�'�Z Structures, TIi�• SCREEN OPENHOLE �8IIt11S Char�iaad• Make,JO�'IIIS�ri from e.to ft. 8 2 Z 9th AvS. SE Type C�a i p� Ac�__C�_�oo��Diam. 'f� C SIoUGauze �n� Length n� '�i i n n e a p�1 i s, M's1. 'rJ J 4�.� Set between��_fl.and_��_fl. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME ?�S2 t�❑ below ❑ above land surface Date measured 1_=.�i_��8 ' PUMPING LEVEL(below land surface) s, Well owner's mailing address if diflerent than property owner's address indicated above. . ft. afler hrs.pumping.�� g.p.m. WELL HEAD COMPLETION �] Pitless adapter manufacturer ��;��a�.�� Model CJ Casing Protection _�J 12 in.above grade � ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? }�] Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Giout Materia� ❑ Neat cemem ❑ eentonite ❑ Concrete�O High So�ids Bentonite MATERIAL from_Q_to_3II_tt. �__ ❑ yds�] bags from __to____ft. ❑ yds. ❑ bags C�.c1 Gre � 1 from to ft. ❑ yds. � bags NEARE T N L[J�SOURCE OF CONTAMINATION_ / �� feet directi��type Sand Gravet � � Well disinfected upon completion9 �] Yes ❑ No Brown C 1 a � �PUMP ❑ Not installed Date installed_ = i o� T8 Manufacturer'sname �AC3 TcICkP4' `SanC� � �Modelnumber ��(�('ri�tCl _f'NC9 1 �� Volts77� Length of drop pipe �� ft. Capacity _ i�g.p.m. ? Pressure Tank Capacity Type:�] Submersible O L. .Turbine ❑ Reciprocating ❑ Jet ❑ _ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes ,�{7 No VAFIANCE Was a variance granted from the MDH for this well? ❑ Yes .�l No WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed 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 repon is true to the best of my knowledge. DON sT�r��r.n, w�r.r. nRILLIN�. C9. �N�. .;. L�cens Busmess Name L�c.or Reg.� a 271�2 j�;,� I-29-99 _ --r . ,. /� - ± l / ''. � �Authonzed Repie ative rgnature " Date < C�uck �Ioore 1-25-98 Name ol Driller Date LOCAL COPY 5 910 S 2 HE-01205-05(Rev.t/95)