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f ' ' ��` '�, �'�'� I`?"'� � � R _�<' � . �F, WELL IOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD �. � 6 7 3 H 9 2 � Rennepin Minnesota Statutes Chapter f03! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. drono 118 2? 27 ,. ,. ,. 200' 4-I8-02 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 2�C)S Ci� Rd b 0�."Q110 � 55 �6 �7 CableTool `❑�riven ❑ Dug 17 Auger �Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of.well location. ❑ _____ ____ "�v� {�}-v' �Showing property lines, � �� roads and buildings. DRILLING FLUID WELL HYDROFFACTURED? L YES O N water i i � i " FROM R.to.__. ft. _i _i_ ___ _i_ ,._. USE ❑ Monitoring ❑ Heating/Cooling i i i i _.._,_,,,� � Domestic _i_ _�_ _�_ _i_ �� . ❑ Irrigation ❑ Community PWS ❑ Industry/Commercial i i i i �-�` hh ❑ Noncommunity PWS ❑ Remedial . w e T � � ❑ Environ.Bore Nole — i i i i 4.�,�� ❑ Dewatering ❑ i i i i ,/zlMie ? CASING Drive Shoe? ❑ Yes �No HOLE DIAM. i i i � '� ❑ Steel ❑ Threaded ❑ Welded -i- -i- -i - -i "{ „� �'Plastic ❑ S �-t Mile-� �•.� -� �3 CASING C�AMETERZ�� WEIGH�� /o �� PRTOPERT OWNER'S NAME �� in.to ft. Ibs./tt. ��i�.�a .. - J�hn�Diane Macesh in.to ft. ___ Ibs./ft. "�li�.�p o0 Property owner's mailing address it different than well location address indicated above. — .— in.to ft. __ Ibs./ft. in.to ft. � �a�� ebove SCREEN OPEN HOLE Make J2hnson from ,__ ft.to fl. Type�_t$_�-��_...�*1 Diam. _ SIoVGauze_.____,_.�ViA Length t. t } t��__. r� Set between ft.and ft. FITTINGS: STATIC WATER LEVEL �� p WELL OWNER'S NAME �___ _tt.�below ❑ above land surface Date measured__�=j Q� 2 . i s_ ' PUMPINGtEVEL(below land surface) �t _ Well owner's mailing address if different than property owner's address indicated above. 1�Q k. after.___�___ _hrs.pumping G S g.p.m. WjLL HEAD COMPLETION W L CN�C e C ----- �"t Pitless adapter manufacturer_ Model �". ❑ Casing Protection__ _.�12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete Hi h Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � 9 from__�_to___�Q._ft. � ❑ yds.�bags p from__2�__to �Q7 ft. �a��.�.�_� 1��] bags ��P`g�� C� S��`� Q � from to ft. ❑ yds. ❑ bags r9 e NEA/R��,i�T,�K�t�1pWN SOURCE OF C01�f�l=CCG�A�QAL t7 �"� �. ` .ry C�gy �r8y .g�lt .7 Zv � _feet _�_ �� direction��j��G �L type Well disinfected upon completion? j�Wes ❑ No �t�'"� �--� r� clay brown soft 1$ 14� � PUMP sand brown SO�t ��0 1 GO � Notinstalled Dateinstalled ��G _ 1V Manufacturer'sname BLC�fJt�C �� v�$V �ort ��^ �S� Modelnumber____._ �� HP_� _ Volts "�" a .7 i V Lengih of drop pipe.____ ft. Capacity ____ _g.p.m. BBAd gr8v $��t !$� 200 Type: �Submersible ❑ LS.Turbine ❑ Reciproca[ing ❑ Jet ❑ _ J ABANDONED WELLS Does property 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 TNri WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. - -- Do� Stadole �Ie12 D�illing Co. , Inc. 2 272 , ,:._._.._:. :,.�� - --- ---- - � Licensee Business ame - -. .-�Lic.orJ7eg.No. �`"i^ � ; ` ' � 7-16-OZ �°.� �� ` � uthorizedRepresentativeSignature ' ' Date ��r�r C�r�Nn;1�U Chuck Moore 4-18-4 Name ol Driller Date LOCA�COPY 6 7 3 8 9 2 HE-01205-07(Rev.2/99) IC#1ao-oo20