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� `'''_i_�OCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. , �untyName WELL AND BORING RECORD �^y � -, Hcr�nG�l�': Minnesota Statutes Chapter 1031 `�✓ �-J�� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed C�r_cna 11'3 L;; t:4 5 y K. � ; . . `._�__ �. �. �< _ > House Number,Street Name,City and Zip Code of Well Location or Fire Number DRILLING METHOD L�t'�.i .Ci.,vXil��'.�'r:.�} �,c1,;1� (}j:'C'?jji7 t MYl 'J�%:?t:�� ❑ Cable Tool CI Driven ❑ Dug ❑ Auger C%7�.Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of weil location. ❑ Showing property lines, roads and buildings. DfiILLING FLUID WELL HYDROFRACTURED? ❑YES O " ��ntc�t;i��e � � � � Faonn n.ro n. -,- -;- -;- -,- USE ❑ Monitoring ❑ Heating/Cooling i i i i �Domestic ❑ Communi PWS -�- -�- -�- -�' ❑ Irri ation �' ❑ Industry/Commercial � � � � <Ll. 9 ❑ NoncommunityPWS ❑ Remedial �( ❑ Test Well W i i i i E T ❑ Dewatering ❑ -r -�- -r- -r � � � i i y2Mi1e k CASING Drive Shoe? ❑ Yes No HOLE DIAM. _i _i_ _i_ _i_ � � � q_Steel ❑ Threaded ❑ Welded ' ' ' ' as�Plastic ❑ s . �-1 M�ile-� � CASING IAMETER WEIGHT � PROPERTY OWNER'S NAME � in.to ��H. i �U ibs.in. 'fi' i t f �et�r �Anctr4� Cc�n�t.�tny ---��.to h. �bs.�n. �;�.�a`� £s Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R. in.to ft. � � ��;�i i�f�,� �r j:� �!� SCREEN 4., OPEN HOLE R.a j ., � � -,�; Make QLF21 Cil'1 from ft.to ft. �;c�.,n � r:��.rif, M.n. .,�.�_;f .�._� . � 5tee1 Type Diam. SIoUGauze • 11 L� Length � Set between !��t ft.and � �� ft. FITTINGS:_t'u � ��%p '{P7/ g �,:.._�,. STAT�f��IPPfER LEVEL A .��l!��' � - WELL OWNER'S NAME tt. ❑ below ❑ above land surtace Date measured PUMPrVQ I[€VEL(below land surface) r�- �� r3 2 r c: Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m. �LL HEAD COMPLETION �tit��W.tE.'1' Pitless adapter manufacturer Model ❑ Casing Protection_ �.12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMAT10N Well grouted7 ❑oes ❑ No GEOLOGICAL MATERIALS COLOR H MATERIAL�F FROM TO Grout Material ❑ Neat cem�}i ❑ eentor�te� ❑ Concrete y��'iiigh So�ids Bentc�ite from to ft. ❑ yds. ❑ bags l from to ft. ❑ yds. ❑ bags 1'C?� J�1� �+1�c(:�C :i �i � � � from to ft. ❑ yds. ❑ bags NEAR OWN SOURCE OF CONTA ATION� S� T1C �-'�-`-��r Br�3�%�1 C � ' �l' = feet �C7�-� � direction rype � Well disinfected upon completion? p Yes ❑ No Cli'�� t7r�1' � S J�' ' G r-� PUMP � ❑ Not installed Date installed �`✓`�� �:1:y Gr::�%�:l Grey �!i �'i x ' 1 i '� ' AermQ�:ar Manufacturer's name C97KG[.7769 7 • 23C Model number HP Volts �:tTlt� `X':331 tl � �;i ' �� ` r,' - � 1�i Length of drop pipe ft. Capacity g.p.m. Type: Cj:Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes b�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes C'�No WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed 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 oi my knowledge. DC�A! S'i`C?Df�L.�z WEI,� U'RZI,LTivG C�,, , INC. Licensee siness N�me Lic.or67eg.No. /� . �•_--+-•-- :�i'' . � „ �`'� :� . ; <%'� ' �i?—�8-9_ ` _ - .r'. Authorized Representative Signature �� Date i'htic3c f�Ic:c��'� 1 �;-�.8--�4% Name ol Dril/er Date LOCAL CC��Y � �� HE-01205-06(Rev.9/96)