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MINNESOTA UNIQUE WELL 1/�F�L OR BORING LOCATION� MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. WELL AND BORING RECORD County Name �-- � Minnesota Statutes,Chapter 103I � � �6 7 5 �'enne in - , Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 118 3 27 �� " � 0-2 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds � ❑Cable Tool ❑ nven �;Dug Longitude degrees minutes seconds ❑Auger �Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � I S A� lr DRILLING FLUID WELL HYDROFRACTUAED? ❑Yes o Show exact location of well/boring in section grid with"X" \ Sketch map of well/boring location. ��1�� From ft.To ft. � (Y Showing property lines, - N � roads,buildings,and direction. SE �Domestic ❑Monitoring ❑Heating/Cooling �' __j__ ._!__ ___�__ ___;__ ❑Noncommunity PWS n Environ.Bore Hole ❑Industry/Commercial " ❑Community PWS ��Irrigation ❑Remedial `� --�-----=-----=-------- ❑Elevator ❑Dewatering �] ` ' w ; ; ; ; e T CASWG MATERIAL Drive Shoe? ❑Yes ,�No HOLE DIAM. i�n --'-"" ""'""""--�-- ---'-- I ❑Steel ❑Threaded ❑Welded ,� , , , , Mile i �� Plastic _� �� . , , , 1 . . --.--- --r-----�-----.-- CAS W G S � Diameter Weight Specifications ; 1 Mi�e� ,.._.. ��J . _.�..�,.,}.._�. �� "--in.to��ft. ��Tlbs./ft. �alm _�in.to�'�ft. �••' ' �.,.:�1� �y,_� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. _�in.toi�ft. in.to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOIE 1� T�L. L� Make From ft. To ft. reCst L'g� � TYPe_ r�t8 �Ss $t Diam. / / � 1XSlCe� MN 5535b SIoUGauze •�10 Length 4� + �F� Set between �s�n ft.and t 77 ft. FITTINGS ~ ~ STATIC WATER LEVEL Measured from �7 ft.�Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �n ft.after 2 hrs.pumping �2 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,-.� • �3-� � �Pitless/adapter manufacturer � ��..�a�-.�.-,r"`��'R�odCh-� ❑Casing Protection �12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) - GROUTING INFORMA,�T{ION ' Well grouted ,�I Yes ❑No Grout materials ❑Neat cement;[�Bentonite ❑Concrete ❑Other From_�_To��ft. �_ ❑Yds. C Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__�Q_To�,.�'�ft. �s. ❑Bags MATERIAL From_�j�_To�$� r,a �Yds. �Bags NEAREST KNOWN SOURCE OF CONTAMINATION � (�'j$ e � �-J feet ��J-�-�'' direction ��-°--c. type � Well disinfected upon completion? �Yes ❑No PUMP ..� �/� ':..�'..� [i Not installed Date installed " �i ' +� t �� [A1 Manufacturer's name ,'�.`.� - _��v��".`'� �,� Model Number HP�Volts d �� r. Length of drop pipe � tf t ft. Capacity g.p.m. Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WE�LS Does properry have any not in use and not sealed well(s)? ❑Yes �`No VARIANCE Was a variance granted from the MDH for this well? ❑Yes �No TN# WELL CONTRACTOR CERTIFICATION 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. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Hvn Stodola Weli illi Co,. Inc. 1691 Licensee Business N e Lic.or Reg.No. �' �� . `� �� , � rt epresentative'.Si nature Certified Rep.No. Date LOCALCOPY 750675 �� Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6)