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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> lo����,Jaine �P�n��,� I j WELL AND BORING RECORD 5 g 110 0
<br /> Minnesota Statutes Chapter 103/ _
<br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed .
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<br /> Urc>nr. i i ; 2� ; �; ,. ,. ,. 1 "� �—?.(,—9 8 �
<br /> House Number,Street Name,Ciry,and Zip Code ot Well Location or Fire Number DRILLING METHOD
<br /> �7 Cable Tool Driven ❑ Dug
<br /> i(; � � �'.�'USS�X RC:�C1 U�OTIC3� �Tl. ;�yg�,.. � Rotary ❑ Jetted
<br /> Show exact location of well in section grid with"X". Sketch map of well location. "; ��f'7 __ __
<br /> Showing property lines,
<br /> .�—�- _��E Z /� roads and buildings. �. DEi}F..�C1RlG FtUID �2E•I�l Lf�;tA a�.r� - . .
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<br /> _I_ _-_ ___ _I_ . . .. ...
<br /> � - USE � � ❑ Monitoring � Heating/Coo6ng
<br /> i i i i . � � . �].DoF1'lestic ❑ Communit PWS ��-
<br /> � ���O��Irrigation Y ❑ Indusiry/Commercial �
<br /> , J � i ❑ NoncommuniryPWS ❑ Remedial .. ��
<br /> W E �r�-�-'"' r i�'Tesf Welf � .
<br /> i i i � �X - ❑ Dewatering ❑ _
<br /> i , � i ,�'M e _ - GASit�� y Drive Shoe? ❑ Yes ❑ No HOLE DIAM. -
<br /> _� i L _i � �� � .�d��Steel -� ❑ Threaded � ❑ Welded .
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<br /> ,p.Plast�c �
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<br /> ' �—iM�le—� .. ��. .... . ' ".�' ', _ �'' ' ,
<br /> r�., CkSING DIAMETER: : WEIGHT . �� ;
<br /> PROPERTY OWroER'S NAME � in.to__' c i ft IbSJR. in.to�{'ft.
<br /> . .: . - . .. � ' . � . �
<br /> 's t_:t��r `Ei.c?en `Car�p�kny --- ---��.�o =—" - --= ' : -�b5.m �� to n. .
<br /> � � � t
<br /> Property owner's mailing address if ditter�nt than w811 loca4ion address indicated above. in.to tt. . IbsJft.� � f� Jrtf to'����-�tr: ' �
<br /> � � SCREEN_ OPEN HOLE �. �
<br /> � �� �� - ��.1���.::k"i I.�`� �.{��1� _ '. .g"Make T.,.,l,.,.�..,r, from ft.to ft.
<br /> �`1�T'+iG1.t��i y �t�: `"'�3°r 4�3 �`` Type Diam.
<br /> SIoUGauze�;f 1 i l_ � � Length �~ �j � _
<br /> � � Set between � ��7 fl.and � ri. FITTINGS: L�� X 8���j �+��.��
<br /> STA'�JC W�TER LEVEL , �;
<br /> WELL OWNER'S NAME ��' ft. �below ❑ above land surface Date measured �—!�'"'�
<br /> �. � �� � � ��<. � �... '. � �� PUMPING LEVEL(below land surface)
<br /> ..,G t3 i r
<br /> Well owner's mailin§�2ddress itdifferent ihan property owner's address indicated above.� � � `'�"'� tt. after___ _hrs.pumping �� ' g.p.m.
<br /> _. � �- -� � WELL HEAD COMPLETION
<br /> � : � � � �7 Pltless adapter manufacturer �ha..�L E:lh���.l t�f'Y Model
<br /> � �� � � ��'Casing Protection_ �___ � 12 in.above grade -
<br /> � . . - . � � . .� � At-grade(Enviio�mental Wells and Boringg ONLY)
<br /> - �� � - . �� �:� GROUTWG INFORMAFION � �
<br /> � � � ' Well grouted? tj,; Yes �0�No " . - �
<br /> �� HARflNESS OF Grout Material�'.�Neat cement ❑ Bentonite�.��Ct Concrete High Solids Bentonite
<br /> C'iEOLOGICAL MATERIALS CQtOR FROM TO ., � '
<br /> MATERIAL trom . �i to j��' tt � O yds.�7 bags
<br /> frorrG_�to fl ❑ yds. ❑ bags
<br />, ' �, l.a,�. �'.'y. �,;.; ".� L�.l'_�=J±ti�,�, ..� ..�"'.i� , , .. t:.` :.:..� �-7{„:' ': - '... �..;- �from � ^t9 '� n. � ❑ yds. ❑ bags
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<br /> � - -� N�RREST KNOWN50URCE OF GQNTAMINATION � w^
<br /> „� ��r �G�i T I
<br /> :tit". � �i,. V E�� �j�p^�,<•ll4 � F t T�l,£ .t —� � feet _ �,r� �J'f duect�on -•�f/ c ryPe
<br /> ,.-.. ..�. , _�;.�. . ..: ...:.:.. -�,: ,.. ,. •���.:.Well disinfected�uPon cor�npletion? ,$;.Ves .[7 No.:� .: ..:.- .
<br /> `4,�"'.�'�' - Cz.'--..� t;i i I'.1 y,. PUMP� � . � . . ...... -
<br /> � . �.. � . ., ..�,.. , . . . .
<br /> -. �..� :.�� �� , . � :,�,. . .✓ �,. ;�� , , . �� �� f� tJot iqstalletl : -..Dete inst111ed..._� ���_,.a.. -���Ci�� .
<br /> .'L � ,;,� ��' :, � ,� � � �� ManufactUre�snamE __ ____ C.c�`=i 1�: ''� :� .-.
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<br /> ^ : ; . .. �' _ �'. ��Model number __����J� _ FIP_�,__r_,,,Votts., ,,,�� '
<br /> ., ... , . :. . . . . _e:_ :, 3 _
<br /> . ,.-, . Length of diop pipe__ _� h.` Capaaty �U g.p.m.., ':
<br /> , .+ � _
<br /> -+_... - , •.
<br /> :; .� i=T1�: �� Y.'+;T:,.:b:`T��� .:..� �c;�.;-. . � ��' .�`�PressureTankCapacity _�°�$l�' �. , .�.. ,_ . . ��r ..
<br /> �,�. . '7ype p Submersible �7 L.3,Turb�ne' C1 Reciprocaung ❑ Jef 'p__
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<br /> j , ..�: . . . . . . . .' ._ �.�: . , c�.
<br /> �-��ABANDONED WELLS � �.� ��. �.. � �
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<br /> DaQs propeAy have arty not in use and not sealed welF(s)� C Yes ,�7 No, h j�
<br /> . . . ��VARIANCE � . : `"�
<br /> Was a variance granted from the MDH fQnthis well?, ❑ Yes 'p No i=8i
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<br /> ' WELL CONTRACTOR CERTIFICATION� . � � � �
<br /> Use a second sheet,il needed ' This well was drilled under my supervision and in accordance with Minnesota Rules,Chapfer 4725..
<br /> REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge.
<br /> Di�l� ��`C1I3ULA WEl',L �RILLIiVG CG. , INC.
<br /> Licensee Business Name Lic.or Reg.No.
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<br /> F � � ��7�
<br /> ��%e,,,�. ,-�. ����;�-7--�8
<br /> � Aufhonzed Represent live Signature Date
<br /> � L'�'lL1C� �C�CI.CE; �'-��r—�/��3 i
<br /> Name olOriller Dafe `
<br /> ` " � -LOCAL COPY 5 9110 0 HE-0,Za�S,��.„�5> „
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