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WELL!,�ATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CuuntyName WELL AND BORING RECORD �-� �i£'nI�Q��l,Tl Minnesota Statutes Chapter 103/ � 9 6 6 6 6 Toyynship Name To�yn�hip No. Rang�Np. Sectioq,N¢. Fraction WELL DEPTH(completed) Date Work Completed U�U 12 U i i t3 t..� C:t' � _ _; ' n. � '�' �—J f v< v. v. Hok se.fJ�r�ber,�S treet Name,City,and��p Codg.,of Well Location or Fire Number DRILLING METHOD 1�L�� !"��1 E':V�. N. Vl.(3T1Ct� �. ❑ Cable Tool ❑ Driven ❑ Dug ❑ Auger � Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ Showing property lines, roads and buildings. DRIL,�NG F UID WELL HYDROFRACTURED? ❑YES [�",NO N L`�Il�OJI3�.t-° i i i i FROM ft.to ft. _i _i_ _i_ _i_ USE ❑ Monitoring ❑ Heating/Cooling _i_ _a_ _i_ _i_ � {� Domestic ❑ Community PWS ❑ Industry/Commercial i � � i ❑ Irrigation ❑ Noncommunit PWS W e ❑ Test Well Y ❑ Remedial i i i i T , ❑ Dewatering ❑ -r -�- -r- -r i � i i +2IM.1e x CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. _i _ i_ _i_ _i_ �,)�(�(�, ❑ Steel ❑ Threaded ❑ Welded r � � � l tiv h V Plastic ❑ 5 �--1 Mile�� /� �F. CASI�G DIAMETER WEI T ( ' � 1�#� °f'. .3 ! ;/i3 :�' PROPERTY OWNER'S NAME !„ in.to ft. Ibs./ft. in.to ft. t�iat��,r.�ri Cc_2nt_rac�.:inct � in.to n. ibs.in. G i h,i(�o:i �f r: � c Property owner's mailing address if different tha w�ll location a res indicated above. in.to ft. _Ibs./ft. in.to ft. �'>,�r_n; ��., �I��ti l�� t�j'�'�� ,��j�� Qr� SCREEN___�,_,��_�! OPEN HOLE � Make from ft.to ft. �'1�rFnouth, �'�I1. rJ�J�i�t; TYPe vt'?iJ.Il �:i;�.', .i��@ Diam. ^a SIoUGauze �� Lier�gth ��f5 � Set between ��'} ft.and �K. FITTINGS: � � �`�� x� � STATICYV�ITF�R LEVEL . � WELL OWNER'S NAME `�`3 R. �below ❑ above land surface Date measured ��, " �� PUMPING E�( L(below land surface) � �i L . `✓ � �? L:i 1.Z Well owner's mailing address if different than property owner's address indicated above. �' ft. after hrs.pumping g.p.m. W�L HEAD COMPLETION Wh i C eaxa fi er ❑ Pitless adapter manufacturer �odel ❑ Casing Protection 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMA�TyION Well grouted? LPYes ❑ No HARDNESS OF Grout Material ❑ Neat cem nt ❑ Bentoni ❑ Concrete ._C3Hi h Solids Benronite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �� 9 }� from to ft. ❑ yds.t7 bags ��t.)�1 �f��. B1ack ;j �: � 1 from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEARES(�y1�[lOWN SOURCE OF CON��`�1 INATION�a,j� �'�'��r �r�''�y�� `� � ` `'-� �•��feet �..._J{�t1� �"7 direction �� type Well disinfected upon completion? L�Yes ❑ No C��.� E�sr�y �J L�j � �Ef PUMP �^-�Y•'��i � O Not installed Da installed Gr.<a.vel C;>3;:x d b� "iti' ` � Cj�w ' ��ermc , Manufacturer's name �5t f i �,1�,y Grc�.�i�1 Ke(��C(7 U.L eC� � ��?£] Q ��(j r Model number HP Volts � Length of drop pipe 1� ft. Capaciry � '�' g.p.m. Ui].F�C��i�r�3V�,'1. CtJ�I i1'E=.` � � �.�, � � �� i Type: �'Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS �! � Does property have any not in use and not sealed well(s)? ❑ Yes d�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes O No WELL CONTRACTOR CERTIFICATION 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 of my knowledge. Dti�i 5�1 t�Di�i,F: �v�Z,,s_: DRIIyIaIIWG l:t,. , I.RiC. Licensee Busine s Name � Lic.or Reg.No ��j� `., . '. . d - 1�-.s--7 .�, . . ._.. .. . �� AutL.l3.�1_:JS, f'1(.�C.>i�E;.ture �Date 3^-7 I l Name of Driller Date � LOCAL ��Y 5 �� HE-01205-06(Rev.9/96) �