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,� "�- W LL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o tyName WELL AND BORING RECORD �A .� .� � _ � � Minnesota Statutes Chapter 1031 �: I � � � � <;+ To nship Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. x v. �i. Ho se Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD ' l� CableTool ;�7 Driven ❑ Dug � . 17 Auger ,�rRotary ❑ Jetted �`, ,; Sh w exact iocation of well in section grid wi "X". Sketch map of well location. �`-'. _ :: � Showing property lines, - � �� - �� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? [�YES ,�10 N �� Wa t e r .FROM ft.to R. � _i i i i_ � � ,�.1, ---- — i ___ _i_ _i �,,. � 9 USE ❑ Monitoring ❑ Heating/Cooling i i i i C�omestic ❑ Community PWS ❑ Indust /Commercial i � i i i f; Irrigation ❑ Noncommunity PWS ❑ Remed al I ' i I E \ � �.°t^' ❑ Environ.Bore Hole ❑ Dewatering ❑ T \ 1_. i _, -r _r ,/ZMQ CASING DriveShoe? es ❑ No HOLEDIAM. _i i _L_ _i_ � . �' .pl!Steel r�Threaded — ❑ Welded � - �- � � Y 1 Cl Plastic ❑ s �—,Mae—� T-. ' CASING DIAMETER { WEIGHT t PR PERTY OWNER'S NAME 4 in.to_ I`�Oft, _ 2 s Di _Ibs./n. $ in.to �On. Tony Fiden Company _��.to- - h. ----------�bs.�h. �,� ,��$h. Pro rty owner's mailing address it difterent than well location address indicated above. _ _ - .._ in.to_____ft. _____ Ibs./ft. in.to ft. ?� 4100 Berkshire Lane SCREEq��n__ OPENHOLE �-�� i"l��t h� 5711 ��H'i V Make'J_ --p �—_.— t from_. ft.to ft. ,�` Type St_aiFlle..gg $�e�i Diam. -_ SIoVGauze_ __ �_D�_Q__ _.,_Length_.��_.�_. � Set between _____��,�_ft.and__�_��ft. FITTINGS: 7z��s jl1Q„_o_��y� s r STATIC WATER LEVEL Y WE L OWNER'S NAME _____��____fl. C�ibelow ❑ above land surface Date measured A��'Z PUMPING LEVEL(below land surface) Well wner's mailing address if different than property owner's address indicated above. _.��_.,_.___ft. after ��hrs.pumping_�S g.p.m. WELL HEAD COMPLETION �Pitless adapter manufacturer��y�st.�_��_�`_�� Model Casing Protection. _ CYI2 in.above grade .� ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �(Yes f i No G OLOGICA�MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete �'Fiigh Solids Bernonite MATERIAL from_._ �to_'�_ft. _"�__ ❑ yds. f�bags lay browfl soft 0 l.8 from—��o�� K �a��r� �� bags NEAREST KNOWN SOURCE OF CONTAMINAT� -1 ; I�,y �r��7 ��it y0 �Q !�__ feet _---� _ _direction � !.�-� bPe . --��-- , Well disin(ected upon completion9 f�(Yes �; No SLZ� bCONT� SOLL 7O 1�O PUMP CI Not installed Date installed 7�2 t�'OZ Ia r� �OL� 11� �L� Manufacturer'snameA�r�aotor ` t e� A Modelnumber___.--. .------ -- ---_---- HP �..�.__ Volts__.�_�a__ �- �� an� bro� �d�t 1G5 �4C7 Lengthofdroppipe .. ____��____ ft. Capacity ___________g.p.m. r Type: �� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ � ABANDONED WELLS Does property have any not in use and not sealed well(s)? C Yes L�?�Jo i� VARIANCE Was a variance granted from the MDH for this well? �� Yes No TN# WELL CONTRACTOR CERTIFICATION .�.'�Use a second sheef,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. - REM RKS,ELEVATION,SOURCE OF DATA,etc. The informUtion contained in this report is true to the best of my knowledge. s`''01 t} `L 5 �°"`'j I�e�-r�-�-E 17 2 c ine ._ _. Lic. �j.�Jo. • ._....-'I / C17-Y OF U�tpNU �� _. _ �__.-- 14-21-02— Authon ed epr�sentatNe� ignature� Date Chuck Moore 9-24-02 Name ol Driller Date X LOCAL COPY � � 7 8 7 3 HE-01205-07(Rev.2/99) IC#14 -0020