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WELL!,�ATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CuuntyName WELL AND BORING RECORD �-� <br /> �i£'nI�Q��l,Tl Minnesota Statutes Chapter 103/ � 9 6 6 6 6 <br /> Toyynship Name To�yn�hip No. Rang�Np. Sectioq,N¢. Fraction WELL DEPTH(completed) Date Work Completed <br /> U�U 12 U i i t3 t..� C:t' � _ _; ' n. � '�' �—J f <br /> v< v. v. <br /> Hok se.fJ�r�ber,�S treet Name,City,and��p Codg.,of Well Location or Fire Number DRILLING METHOD <br /> 1�L�� !"���1 E':V�. N. Vl.(3T1Ct� �. ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRIL,�NG F UID WELL HYDROFRACTURED? ❑YES [�",NO <br /> N L`�Il�OJI3�.t-° <br /> i i i i FROM ft.to ft. <br /> _i _i_ _i_ _i_ <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> _i_ _a_ _i_ _i_ � {� Domestic ❑ Community PWS ❑ Industry/Commercial <br /> i � � i ❑ Irrigation ❑ Noncommunit PWS <br /> W e ❑ Test Well Y ❑ Remedial <br /> i i i i T , ❑ Dewatering ❑ <br /> -r -�- -r- -r <br /> i � i i +2IM.1e x CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> _i _ i_ _i_ _i_ �,)�(�(�, ❑ Steel ❑ Threaded ❑ Welded <br /> r � � � l tiv h <br /> V Plastic ❑ <br /> 5 <br /> �--1 Mile�� �� /� <br /> �F. CASI�G DIAMETER WEI T ( ' � <br /> 1�#� °f'. .3 ! ;/i3 :�' <br /> PROPERTY OWNER'S NAME !„ in.to ft. Ibs./ft. in.to ft. <br /> t�iat��,r.�ri Cc_2nt_rac�.:inct � <br /> in.to n. ibs.in. G i h,i(�o:i �f r: � c <br /> Property owner's mailing address if different tha w�ll location a res indicated above. in.to ft. _Ibs./ft. in.to ft. <br /> �'>,�r_n; ���., <br /> �I��ti l�� t�j'�'�� �,��j�� �Qr� SCREEN___�,_,��_�! OPEN HOLE <br /> � Make from ft.to ft. <br /> �'1�rFnouth, �'�I1. rJ�J�i�t; TYPe vt'?iJ.Il �:i;�.', .i��@ Diam. ^a <br /> SIoUGauze �� � Lier�gth ��f5 � <br /> Set between ��'} ft.and �K. FITTINGS: � � �`�� � x� � <br /> STATICYV�ITF�R LEVEL . <br /> � <br /> WELL OWNER'S NAME `�`3 R. �below ❑ above land surface Date measured ��, " �� � <br /> PUMPING E�( L(below land surface) <br /> � �i L . `✓ � �? L:i 1.Z <br /> Well owner's mailing address if different than property owner's address indicated above. �' ft. after hrs.pumping g.p.m. <br /> W�L HEAD COMPLETION Wh i C eaxa fi er <br /> ❑ Pitless adapter manufacturer �odel <br /> ❑ Casing Protection 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMA�TyION <br /> Well grouted? LPYes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cem nt ❑ Bentoni ❑ Concrete ._C3Hi h Solids Benronite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �� ��� 9 }� <br /> from to ft. ❑ yds.t7 bags <br /> ��t.)�1 �f���. B1ack ;j �: � 1 from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEARES(�y1�[lOWN SOURCE OF CON��`�1 INATION�a,j� <br /> �'�'���r �r�''�y�� `� � ` `'-� �•��feet �..._J{�t1� �"7 direction �� � ��type <br /> Well disinfected upon completion? L�Yes ❑ No <br /> C��.� E�sr�y �J L�j � �Ef PUMP <br /> �^-�Y•'��i � <br /> O Not installed Da installed <br /> Gr.<a.vel C;>3;:x d b� "iti' ` � Cj�w ' ��ermc , <br /> Manufacturer's name <br /> �5t f i <br /> �,1�,y Grc�.�i�1 Ke(��C(7 U.L eC� � ���?£] Q ��(j r Model number HP Volts <br /> � <br /> Length of drop pipe 1� ft. Capaciry � '�' g.p.m. <br /> Ui].F�C���i�r�3V�,'1. CtJ�I i1'E=.` � � �.�, � � ��� i Type: �'Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS �! <br />� Does property have any not in use and not sealed well(s)? ❑ Yes d�No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes O No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> Dti�i 5�1 t�Di�i,F: �v�Z,,s_: DRIIyIaIIWG l:t,. , I.RiC. <br /> Licensee Busine s Name � Lic.or Reg.No ��j� <br /> `., . '. . d - 1�-.s--7 <br /> .�, . . ._.. .. . �� AutL.l3.�1_:JS, f'1(.�C.>i�E;.ture �Date 3^-7 I <br /> l <br /> Name of Driller Date � <br /> LOCAL ���Y 5 �� � � � HE-01205-06(Rev.9/96) � <br />