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[ . , - WELL LOCA ION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. Ccunty Name WELL AND BORING RECORD � g�4 �1 � in Minnesota Statutes Chapter f031 � �� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed ` c�,o iZ� z3 a ,, �, ,, �4s ft io-to-o� GPS DRILLING METHOD LOCATION: Latitud �� degrees minutes __ seconds . Longit degrees minutes seconds i_J Cable Tool n riven 'Dug -]Auger '�Aotary ❑Jetted House Number,SVeet N e,City,and Zip Code of Well Location or Fire Number � � 31� ds QCOI�X� 55356 ORILLING FLUID WELL HYDROFRACTURED? f]Yes ,'S�QJo �T Shop exact loca ion of w II in section grid with"X". Sketch map of well location. �/$te;' FROM ft.TO ft. Showing property lines, _ ---- � roads and buildin s USE � r� 9 — =" N CI�. `� No cosmmuni PWS �E�i ationB�re Hole J�Heating/Cooling 9 , , ,;✓�� L' ; ��Industry/Commercial :• --'--- ------` �- y� � � �ty � g i Remedial � ��"��'�` '��Community PWS ��Dewatering � --'-- - '--• ---`- ---`- `- CASING HOLE DIAM. �' yy ; i ! ; E� D ive Shoe? ❑Yes ',�No �� r __ � J Steel ^'�Threaded ��Welded 'h Miie � Plastic [] - : ; : ; 1 � : --;-----�-- --� ---:- , CASING DIAMETER WEIGHT S q nt � �- p _ � in.to��ft. b.lJl Ibs./tt. �_in.to_�t. 1 Mlle _ _ ..r. i_1...a. �� /�� A in.to __._fl. _ __ _--1bsJft. �_in.to_I��t. ' PROPERTY O ER'S N E/COMPANY NAME in.to ft. IbsJft. in.to ft. t L CC L � IStL�LiCC1O�I SCREE OPEN HOLE Property owner' mailing daress if differert than well location address indicated above. Make �� 8�gt��e��-a�- FROM_ ft. TO____ f[. _� 55� r�o�m Dr TYpe - 1 01.1 Diam /�,* _.. - --._ — _ - .. �L�J.� i'A� �'�'.J J'�FJiJ SlotlGauze _�LA� _ __Length___ .��._'�' �� . ._ _ _ � ! ' Set between_1�___ ft.and__l��_ft FITTINGS_�~ ~ STATIC WyAT�ER LEVEL y " I�?-Ifl-43 ; - !�_ ft.�below �,__above land surface Date measured_____ ___ _. , PUMPING LEVEL(below land surface) WELL OWNER' NAME/ MPANY NAME ' ` 137 _ ft.atter __� hrs.pumping � g.p.m. WE HEAD COMPLETION �t��er } Well owner's mai ng addr if different than property owners address indicated above. itless adapter manufacturer________ . _ _ Model_ �Casing Protection _ ._ __ ____ in,above grade �--1 At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted �es j-�,�No Grout material ��, �Neat cement ['�.Bentonite �._Concrete �gh Solids Bentonite from�_to_�_ fl. _ .�_ _�.yds. �ags from__�_to�,�_ft. ('}$,tjj�� _'�bags .�� � GEOLOGIC L MAT ALS COLOR HARDNESS OF FROM TO from_ to_____.ft. _ ____.._ I�Yds. �,_,'�bags �n MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION �� feet --- direction ��'� �' 'ty�e clay yellow ft 0 18 - - — � — -- . Well disinfected upon completion Yes ❑No ��-' C� �j�av �ft �� PUMP J io-u�-a�3 -�� ;J Not installed Date installed_.__.. __ __ �. �� a�� ft [fA '1�$ Manufacturer'sname_ �r��.._� ___.--.— C� 7tJ A Model number ` HP ��Volts `� Length of drop pipe ��v ft Capacity _ ___g.p.m. � Type:� ubmersible �LS.Turbine ',J Reciprocating �`��Jet ❑ � ABAN ONED WELLS Does property have any not in use and not sealed��ell(s) _j Yes j o � VARIANCE S Was a variance granted from the MDH lor this well? ��';Yes � o TN# �` � WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules.Chapter 4725. The informatlon contained in this report is true to the bes�of my 4;nowledge. seasecondsheet,i/needad DonSLodola t�ll �iiling Co�� Il�• G7�72 REMARKS,ELEV ION,S RCE OF DATA,etc. Licensee Business ame � '.or Reg.No. i� � f. '�� Il-I8-03 : - ----- __ ._ __. --- rize epre entative SignaC�r`e� Date c�k rwo� It3-1p-03 OCAL COPY 6�6 4 81 Name olDriller �ate HE-01205-08(Rev.5/02) IC 140-0020