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Icn,y OR BORING LOCATIONMINNESOTA DEPARTMENT OF HEALTH MIN ASND BORINGG NOELL Name WELL AND BORING CONSTRUCTION RECORD 810863 T It Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 7. Ornnn' 118 714 33 SE SE 203 4-22-15 �= GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD V co Latitude Longitude ❑Cable Tool ❑Driven ❑Auger Rotary N 07 House Number,Street Name,City,and ZIP Code of Well Location –'Other C Q2420 Warartilum -11 1 DRILLING FLUID WELL WELL HYDROFRA Ufjy ❑Yes No Show exact location of well/boring in sec ion d with"X:' Sketch map of well/boring loca bentonite I I rF Showing property lie From ft.To dRn roads,buildings,and direc on. USE N � �Domestic E]Monitoring ❑Heating/Cooling ___ __;_____ ;__ 1�- b ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial } ❑Community PWS ❑Irrigation ❑Remedial ❑Elevator E]Dewatering ❑ C — - --- v/ E T CASING MATERIAL Drive Shoe? ❑Yes )4 No HOLE DIAM. ' ❑Steel ❑Threaded ❑Welded 'h Mile ❑ ; 1 Plastic CASING S Diameter Weight Specifications 1 Mile � �.;_' gyp.,,.. [A�f„-- (� _4 in.To 1498 ft. lbs./ft. _8_in.To__W. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. v,�in.TO-207- Terri Kenworthy in.To ft. lbs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE same Make stainless $ From ft. To _ ft. Type Diam. Slot/Gauze Length 19 Set between_198_ft.and ?n_1_ ft. FITTINGS- ~ f _ STATfffER LEVEL (( Measured from _ ft.$Below F]Above land surface Date measured 5 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 190 ft.after hrs.pumpingP.P.M. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer whiteimter Model ❑Casing protection 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material neat cemgAt 0 To 50 ft. 3 ❑Yds. XBags MaterialnatrUall _30To 198 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. E]Yds. E]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To __Bags /r�� NEAREST KNOWN SOURCE OF CONTAMINATION topsoil black um 0 4 1 W# feet S direction c f v $ewer ype Well disinfected upon completion? Yes E]No `_, clay tan medium 4 13 PUMP E]Not installed Date installed 4-25-15 sandy clay gray 1381 13 54 Manufacturer's name Schaefer gravel/sand mix courlse 54 109 Model Number HP 3/4 Volts 2,3n 1 Length of drop pipe 147 ft. Capacity 9-p.m sandy clay gray diu111 09 152 Type: Submersible ❑L.S.Turbine ❑Reciprocating E]Jet El ,.,"7ed ABAN ONED WELLS Sand redish br m52 180 Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE sandy clay/gravel red 111ediumm 1n/80 Was a variance granted from the MDH for this well? E]Yes No TN# C7lJ 7�f WELL CONTRACTOR CERTIFICATION 1�,�. r� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. Use a secoM�sl sand needed. Mel iM 94 205 The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. Ton Stodola 'dell Drilling co.2 Inc. 1691 Licensee Business Na a Li or Reg.No. / it w _ ertifi d R esehtative Signature Certified Rep.No. Date LOCAL COPY 810863 Name of Driller Rob S todola IC 140-0020 HE-01205-15(Rev.8/13)