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' '� MINNESOTA DEPARTMENT OF HEALTH M'N AND BORINI�G NO. ELL
<br /> WELL C)R BORI�JG LOCATION
<br /> � ca���Y N,me WELL AND BORING RECORD 7 g 2 016
<br /> � �� Minnesota Statutes,Chapter 103I
<br /> Township Name Township No. Range No:. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> Ora� I18 23 29 I+I�iSW SE �� "
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds ,�
<br /> �- Longitude degrees minutes seconds ❑Cable Tool i,_'i Driven
<br /> , ❑Auger �Rotary
<br /> House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other
<br /> 3515 Si=th Avoe N Orot�a 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No
<br /> �+� Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �tVlLLt� From ft.To ft.
<br /> Showing propert lin ,
<br /> N J �roads, ' 'ngs,and d� c n. USE �Domestic _.Monitoring �]Heating/Cooling ;
<br /> � , � � "� .. '�- - ::
<br /> __;___ ___,__ ___;_. �� ��r�Noncommunity PWS [�Environ.Bore Hole ❑Indushy/Commercial "
<br /> � ���,_]Community PWS ❑Irrigation ❑Remedial
<br /> �` --�--- -�-----�-- --�-- ��Elevator ❑Dewatering [] �
<br /> -�: w ; ; ; ; e T CASING MATEAIAL Drive Shae? ❑Yes o HOLE DIAM.
<br /> � --;-----�------�--->-- ,. . � �.
<br /> I ❑Steel ❑Threaded , ,Welded
<br /> -�� , , , , Mile
<br /> ��' � Plastic ❑ �-
<br /> : ------------ --.-----:- 1 �
<br /> CASING
<br /> S � Diameter Weight Specifications -
<br /> �1 Mile� � in.To �7� ft. Ibs./ft. __ �in.Tog�ft
<br /> � PROPERTY OWNER'S NAME/COMPANY NAME •• " ,' — in.To ft. Ibs./R �in.To�v�_.ft
<br /> i�t��L�
<br /> j in.To R. Ibs./ft. in.To ft
<br /> �`e �t�=� � �� OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. SCREEN�-�4 __
<br /> � Make +���1������ _ From _ft To ft. �
<br /> —1 - _♦ .
<br /> Type ,�tSlri����$t�l Diam. �
<br /> :. SIoVGauze ��(3_. . __. Length��I �_�1 '.
<br /> Set between ft.and it. FITTINGS
<br /> STATIC WATER LEVEL Measured from
<br /> 93 _�_
<br /> ft.' Below ���, ��,Above land surface Date measured
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> :,� a� ft.after_--- 6 ____..---__._hrs.pumping � g.p.m. ��.
<br /> ; Well/boring owner's mailing address if ditferent than property owner's address indicated above. WELLHEAD COMPLETION ♦
<br /> �;Pitless/adaptermanufacturer�F�te� Model
<br /> _ ❑Casing protection _ __ �'12 in.above grade c
<br /> ❑At-grade ❑Well House �Hand Pump
<br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
<br /> Matenal[7C[I�I�From Q_To____��tt. __3��Yds. �ags
<br /> Matenal[�� l/'A� f'kr�ri.___�To�7�ft. U Yds. ❑Bags
<br /> �� HARDNESS OF Material . ._,,_From To ft. [�Yds. ❑Bags ';
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION �
<br /> ) � / r^��_� � ,...,�� �
<br /> to�il laek �o s,��C..�� feet �`r direction _C'�'4.�^"f"�' type
<br /> \ `
<br /> Well disinfected upon completion? ,�J.Yes ❑No �
<br /> CI$ � PUMP
<br /> ❑Not installed Date installed___ �1��1�
<br /> e� Manufacturer's name_ �i�€e�___ _ __..__.
<br /> Model Number_ ___ HP�___Volts
<br /> �/ r�@� Length of drop pipe�(„S7 ft. Capacity _.__. ____g.p.m
<br /> ___ 4,� � Type: -' ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
<br /> S8[iCl
<br /> ABANDONED WELLS
<br /> `�„� � Does property have any not in use and not sealed well(s)? ',^.I Yes o
<br /> sO�ai F
<br /> VARIANCE
<br /> F
<br /> 1
<br /> � r�! Was a variance granfed from the MDH for this well? ❑Yes No TN#
<br /> WELL CONTRACTOR CERTIFICATION
<br /> �1�Q(�j/ This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> ,���/ ��� The information contained in this report is true to the best ot my knowledge.
<br /> 7a{ai/ Use a second ded.
<br /> -. REMAFKS,ELEVATION,SOURCE OF DATA,etc. �' Sa....l�1_ tt�1 S1,.J 1!{�,� t���' ZnGs �II7�
<br /> ��L�SVlti RC 1 iJf.allias,�-� 4N
<br /> � Licensee Business Name Lic.or Reg.No.
<br /> /` ., '" &-2-13
<br /> �g C e r sentat e Sign re Certified Rep.No. Date
<br /> 1
<br /> ,
<br />-- Rob SLod02e
<br /> LOCAL COPY 7 9 2 0 1 6 - - - °
<br /> Name of Driller �
<br /> IC 140-0020
<br /> � HE01205-13(Rev.11/10)
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