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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 612 �0 6 ��r�'��.�" Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �rc�nt I1� ^� 3a �,,, ,{�',� {�"t.t�t�. If�? �� 12/7/9� House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug „ 4%rs5 Stut3bF h�v Ro�d, I.n-�q I��ke 5S 55 ❑ Auger Ltl(Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ � Showing property lines, ... - roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO N �.�..�.�..�'_"'.^-•'y `�_��.p� ,� WK`�� FROM ft.to ft. i i i i - -i -�- -�- -i- � }.!.r '= ,�_.�--�--•'"� USE ❑ Monitoring ❑ Heating/Cooling i i i i L\, f3�pomestic _i_ _�_ _�_ _i_ �--"`� � ❑ Community PWS ❑ Industry/Commercial � � � � � �, `'\ � ❑ Irrigation ❑ Noncommunit PWS ,�,�t ( i Y ❑ Remedial w ET i,�i � ❑ TestWell i i i i �� ' � ❑ Dewatering ❑ i _, i -r ��zlM,ia . ' CASWG Drive Shoe? ❑ Yes o HOLE DIAM. _i i i i_ � ❑ Steel ❑ Threaded ❑ Welded i _i_ _i _ _i � O�Plastic ��L1" s �1 Mile� �J/_��,� � !� � - � CASING DIAMETER WEIGHT n PROPERTY OWNER'S NAME � in.to 1 b� ft. IbsJft. �?�in.to��yft. ��P.�,1�;c'3'1'�.�.. .jL!G�II?'e� in.to ft. Ibs./ft. �in.to_lV�ft. Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. 14$S S��I�'?�`i£• Bc:.� RCY:'f`�I SCREEN OPEN HOLE �.f')32�y �,�l.�R.'.y �":Ri 55355 Make a�� from ft.to ft. Type �Y�+ Diam. � SIoVGauze '� Length �� set between j� ft.and 167 ft. FITTINGS: K""�8�IC�I STATIC WATER LEVEL , WELL OWNER'S NAME ��4 ft. [�below ❑ above land surtace Date measured �n$}'��' PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m. WELL HEAD COMPLETION �; ❑ Pitlessadaptermanufacturer ��"�`-�`��' Model � ❑ Casing Protection_ ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? L�Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ,��entonite ❑ Concrete ❑ Hi h Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from � Yto �3 ft. 3 9 ❑ ds. —r y lri bags from to ft. ❑ yds. ❑ bags Clsy Yelio�T (} 3� from to n. ❑ vd5. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION x�� C�.'�=� rT`�� feet direction type Well disinfected upon completion? L�Yes ❑ No � S:3"'L(3I�I'i1VQ�. Ei�B�j' �O I1� PUMP / ❑ Not installed Date installed 1 D��9� Cl<�y/S,^;:�c1 ��c� 12Ct I55 �ty�rs Manufacturer's name uii�l��'r'�3;'+P,�_ '7�{�i..t��,rj��, ?l' 1 r�c, ��? Model number ��t HP Volts �C Length of drop pipe ft. Capacity ^� g.p.m. Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS y , Does property have any not in use and not sealed well(s)? ❑ Yes ❑'No . VARIANCE v Was a variance granted from[he MDH for this well? ❑ Yes C3�No 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,etC. The information contained in this report is true to the best of my knowledge. �E��EIV4�� `e�sc�i�g i�rz1l;r.g & ?�,r.t=. S�X'11�Ct?S� �'�b55k . Licensee Business Name Lic.or Reg.No. �� 2 b 1999 ��Qg Authorized Representative Signature Date C;� � C7F ORC�;�'C� �'.��c�� Fe�*�::s:�r � Name ol Driller� Date LOCAL COPY C�� 7� � HE-01205-06(Rev.9/97)