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MINNESOTA UNIQUE WELL <br /> WL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD 760618 <br /> �� Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> MIMI, 118 23 32 216 tt' <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds Auger <br /> Cable Tool L]Driven Dug <br /> ❑Auger ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location �or Fire Number n . . " <br /> .3%0Watutom Ris Omw U359 DRILLING FLUID - HYDROFRACTURED? [-]Yes o <br /> Show exact location of well/boring in ction grid with"X" Sketch map of well/boring location. t�t�= From ft.To ft. <br /> Showing property lines, <br /> N (J roads,buildings,and direction. USE omestic ❑monitoring y� g ❑Heating/Cooling <br /> �� Noncommunity PWS ❑Environ.Bore Hole L]Industry/Commercial <br /> �� ❑Community PWS ❑Irrigation ❑Remedial <br /> ---- -----F-- -- -- ❑Elevator ❑Dewatering ❑ <br /> W E ` CASING MATERIAL Drive Shoe? ` <br /> Yes I�l HOLE DIAM. <br /> -�--- - --�-----%-- y ��o -.. <br /> T ❑Steel ❑Threaded ❑Welded <br /> 'h Mile lastic ❑ <br /> 1 CASING <br /> S Diameter Weight Specifications <br /> 1 Mile 4 in.to 21% ft. 1.9Ibs./ft _B_in.to — fit. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft in.to-M. <br /> Boyec DEl3 <br /> a.2 4.i.dlft in.to ft. lbs./ft. in.to ft.Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE <br /> 3435 ety Rd 101 MakeJbbFrom ft. To ft. <br /> �onlm, iV 5�5 Type e w Length <br /> , Slot/Gauze •�viA Length 411 4 4* <br /> Set betweenft.and ft. FITTINGS *21 <br /> pip <br /> STATIC WATER L Measured from <br /> 112 ft. elow ❑Above land surface Date measured <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after I jS hrs.pumping 30 9.p-m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,} <br /> ❑Pitless/adapter manufacturer <br /> ❑Casing Protection EX in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted FXes ❑No <br /> Grout materials ❑Neat cement [Centonite [_1 Concrete ❑Other <br /> From 0 To 30ft. 3 '❑Yds. L_�Cags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From Toft. [:]Bags <br /> MATERIAL From To R ❑Yds. ❑Bags <br /> y. <br /> NEAREST KNOWN <br /> .s WN SOURCE OF CONTAiMINATIION <br /> C � 1e& /16 :7c feet ! <br /> direction _N type <br /> Well disinfected upon completion? es ❑No <br /> el" 9M ft 16 12D PUMP <br /> ��p <br /> F]Not installed Date installed <br /> �1 soft 1120 140 Manufacturer's name /.� -�"4'>--•-�Y^�—'11 <br /> CIAY be. soft <br /> 3E�l <br /> ft �y Model Number f HP .;� Volts <br /> Length of drop pipe ! �+� I ft. Capacity g.p.m. <br /> �..�) bvow i7ii7� 2W 216 Type: ubmersible [_]L.S.Turbine L]Reciprocating ❑Jet ❑ <br /> !+i 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 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,h needed - - <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Dw 3todols WeU DrUUng co., rw. 16% <br /> Licensee Business Name Lic.or Reg.No. <br /> `7` ld j <br /> Ce r entative Slg atureCer4 ied Rep.No. Date <br /> momLOCAL COPY <br /> 760618 Name of Driller —_ <br /> IC 140-0020 HE-01205-11(Rev.3/07) <br />