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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Minnesota Statutes, Chapter 1037 726426 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Ormo 1127 23 S 14 ,/ 215 l 12-14-0 <br /> GPSILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds P ❑Cable Tool y ❑Dug <br /> Auger k'Drivern <br /> otaJetted <br /> ❑ <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number '. ❑ <br /> 825 <br /> Rd © ! DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Tordcm <br /> Show exact location of well in section grid with"X'. J Sketch ap of well location. <br /> Sh in roperty lines, bmto 1ite FROM ft.TO ft. <br /> N r nd buildings USE <br /> ❑Monitoring ❑Heating/Cooling <br /> �. omestic ❑Environ.Bore Hole <br /> ________ /? yam✓ ❑Industry/Commercial <br /> K <br /> T:Noncommunity PWS ❑Irrigation ❑Remedial <br /> ❑Community PWS ❑Dewatering ❑ _ <br /> , f <br /> CASING HOLE DIAM. <br /> W I T Drive Shoe? ❑Yes 00 <br /> ------ ------- }__ ;__ I ❑Steel ❑Threaded ❑Welded <br /> , 'h Mile <br /> 1 � Plastic <br /> / <br /> ASING DIAMETER WEIGHT <br /> s <br /> in.to_.207__ft. lbs./ft. 8 in.to-30 ft. <br /> 1 Mile It n.to lbs./ft. I in.1 15 ft. <br /> ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAMEd,? in.to ft. lbs./ft. in.to ft. <br /> SCREENOPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. MakeJ hnsw - FROM ft. TO ft. <br /> Dr 4420 Shoreline SfL Type aboin eas 90 <br /> Diam. 2n <br /> ng Pack, MN 5533'. Slot Gauze Length <br /> rK1 J ��'t Set between a t.and ft. FITTINGS _ <br /> STATIC WATE L 4A.7 4116 all <br /> ft. below ❑above land surface Date measured <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ' <br /> 210 ft.after hrs.pumping so — <br /> 9-p.m-WELL HEAD COMPLETION (� <br /> Well owner's mailing address if different than property owners address indicated above. )(Pitless adapter manufacturer'k Y'C—, odel <br /> ❑Casing Protection X12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted ,Yes ❑No <br /> Grout material ❑Neat cement ❑Bentonite ❑Concrete XHigh Solids Bentonite <br /> from___to 30 ft. 3 [:1 yds. Xbags <br /> from IN ft.njjtAjL-4Lj—fn2. E]bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from o . <br /> MATERIAL tft ❑yds. E]bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> -4 .r% I feet Lj direction t <br /> C. rq .+—tYPe <br /> Well disinfected upon completion XYes ❑No <br /> PUMP <br /> ❑Not installed Date installed I,-:) <br /> CJ.S <br /> Manufacturer's name <br /> jZray <br /> Model number `` HP J Volts ' } <br /> } Length of drop pipe /l;�Ca ft. Capacity g.p.m. <br /> Type: ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s) [-]Yes o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a econd sheet,it needed - <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Busine s ame L C.or Reg.No. <br /> tho e Rep r sentative Sign re f Date <br /> James Kohls <br /> 1726426 � Name of DrillerLOCAL COPYHE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />