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4 _ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD <br /> Hmmon Minnesota Statutes, Chapter 1031 705924 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Aram 23 32 lit. '/ <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> ❑Auger Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number ❑ <br /> Watiortam Rel- Ornm 553M DRILLING FLUID WELL HYDROpRACTURED? YesFlo <br /> Show exact location of well in section grid with"X". Sketch map of well location. FROM ft.TO // tt. <br /> Showing property lines, <br /> N roads and buildings USE <br /> _ i� Monitoring ❑Heating/Cooling <br /> `p Domestic <br /> ____________�_____,_ Environ.Bore Hole ❑Industry/Commercial <br /> Noncommunity PWS ❑Irrigation ❑Remedial <br /> Community PWS ❑Dewatering ❑ <br /> CASING❑ HOLE DIAM. <br /> W E # Drive Shoe? ❑Yeso <br /> 1 El steel El Threaded Elelded <br /> Mile (t <br /> r ,h lastic ❑ <br /> 1 CASING DIAMETER WEIGHT <br /> 1 Mlle <br /> 1' in.to 184 ft. 2.01 lbs./ft. a in.to -40 ft. <br /> --i � p ��'j� <br /> n.to ft. lbs./ft. W in.tit. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.toff. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing ddress if different than well location address indicated above. MakeJbfil� FROM ft. TO ft. <br /> Type stainless stl Dm. <br /> ia <br /> Slot/Gauze -010 Length 4! + 4! <br /> Set between ft.and ft. FITTING M <br /> STATIC WATER LEVEL <br /> 100 tt. elow ❑above land surface Date measured 4-29"M <br /> PUMPING LEVEL <br /> WELL OWNER'S NAME/COMPANY NAME (b,eIA land surface) <br /> - ft.after 2 40 hrs.pumping _g.p.m. <br /> WELL HEAD COMPLETION <br /> Well owner's mailing address if different than property owners address indicated above. 0itless adapter manufacturer Adtewter Model <br /> Casing Protection X12 in.above grade <br /> ❑At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted OIYs [—]No <br /> Grout material Neat cement ❑Bentonite ❑Concrete [�iigh Solids Bentonite <br /> from to 30 ft. 3 ❑yds. gs <br /> from--"30�. to ft. jj�jj bags <br /> HARDNESS OF +•^ � � <br /> GEOLOGICAL MATERIALS COLOR FROM TO from o ft. <br /> MATERIAL t ❑yds. ❑bags <br /> NEAREST/KNOWN SOURCE OF CONTAMINATION <br /> ft_7 feet direction A. <br /> Well disinfected upon completion es ❑No <br /> PUMP <br /> cuy VAI I nu soft <br /> ❑Not installed Date installed 5-3-04 <br /> II-1 av sof t 38 140 Manufacturer's name Aecwto <br /> gray Model number HP 1 Volts 230 <br /> sand rave I . 1h boamt— soft j4j0__ 192 Length of drop pipe 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 Wo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes o 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 second sheet,if needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> r a <br /> Licensee Business 27172 <br /> N e fc.or eg. <br /> o d res n ti Si ` Date <br /> Chuck Moore 4-29-04 <br /> IC 140-0020 LOCAL COPY <br /> 1705924 Name of Driller <br /> _ HE-01205-08(Rev.S/02) <br />