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<br /> WELL OR BORING LOCATION
<br /> MINNESOTA DEPARTMENT OF HEALTH MIN AEND BORINIQ NOWELL
<br /> �o �YName WELL AND BORING RECORD 7 c� 2� 6 6
<br /> Minnesota Statutes,Chapter 103/
<br /> �
<br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED
<br /> �r ' n� a� ��� N� 13C� ,� N � a�� p
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees _ minutes seconds ._
<br /> Longitude degrees minutes seconds ��]Cable Tool I ��Driven Dug
<br /> --- Y�Auger �!Rotary ',]Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Locatiory_,� or Fire Number - - ��
<br /> y ��� �,r��. A �� /)r�7J DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No
<br /> i/
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. ��_��f` From ft.To ft.
<br /> Showing property lines, —
<br /> roads,buildings,and direction. USE �
<br /> N �Domestic _Monitoring ��j Heating/Cooling
<br /> __j_____j___ __;__ _ !__ - . ,. ',Noncommunity PWS � )Environ.Bore Hole � �Industry/Commercial
<br /> �]Community PWS L Irrigation _.��;Remedial
<br /> --�-----;--- --�-- ---�-- '�I Elevator ❑Dewatering [�
<br /> w ; ; ; ; E� CASING MATERIAL Drive Shoe? '�����Yes �No HOLE DIAM.
<br /> c�
<br /> --'--- --'------�-----'-- � . !�Steel ':_',�Threaded �L_�.Welded
<br /> , , , , '/Mile "_'�-'..^"^"`.,,�.....- "`
<br /> , , , , �� Plastic '
<br /> --,--- --,-- ---�-- ---�-- i U. � ��
<br /> ; ; � � CASING
<br /> S � � � Diameter Weight Specifications ` }�
<br /> �1 Mile—� I'f%"�1�.�j ._"j_ ___in.to. '�� ft Ibs./ft. �/�in.to�v ft.
<br /> f
<br /> PR TY OWNER'S NAM iCOMPANY NAME in.to ft. Ibs./ft. in.t�t.
<br /> �y in.to ft. Ibs./ft. in.to ft.
<br /> � (�4V�� �.��V�
<br /> Property owner's mailing address if different than well location address indicated above.
<br /> SCREEN OPEN HOLE
<br /> ��[ K //'��, � . Make From ft. To ft.
<br /> G%�.J l�f��•1���✓ � TYPe -1F-� _ Diam.
<br /> y + . � � ��� � Slot/Gauze -�t � / Length {�
<br /> �� � G.�� ��`�'� ���� -�'' �"l Set between. �" ft.and__��c�ft. FITTINGS t�l �!�':-�'.r
<br /> STATIC WATER LEVEL
<br /> Measured from �* --�...
<br /> ��_,. ft.� Below [J Above land surface Date measured_�L__.�. �j(�
<br /> W, OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> �� { ,(. �"E � (_�( �i..'� ft.after__ hrs.pumping�(,� g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION //
<br /> Pitless/adapter manufacturer__ ���'� Model
<br /> j_Casing Protection_ _ __ _ _12 in.above grade
<br /> At-grade(Environmental Well and Boring ONLY)
<br /> GROUT G INFORMQ.TION
<br /> Wel�r�e� es � �No� �� �(
<br /> Grout matenalsi��_. eat cement ,_;Bentonite . �Concrete ',�'Oth� _ i'� ___
<br /> From To_. _fl. �.__Yds. ,J Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft ��,_�Yds. (�Bags
<br /> MATERIAL From To R. �._Yds. �,�Bags
<br /> � � � NEAREST KNOWN SOURCE OF CONTAMINATION��/?� ijrri �(,,l,J�{:,
<br /> � � � G'�L�`�-"� � � �� feet direction type
<br /> � ��` Well disinfected upon completion? �Yes [J No
<br /> �.��1.� "^� PUMP
<br /> �� �� j 'Not installed Date ins Iled /� �I� ���
<br /> �� � Manufacturer's name �
<br /> �'}'� I� Model Number HP Volts
<br /> �-t �C� '% / J
<br /> Length of drop pipe_._�__ R. Capaciry ��_g.p.m.
<br /> Type:��. Submersible LS.Turbine ❑Reciprocating �,�Jet �]
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? ❑Yes �No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ;J 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 inbrmation contained in this report is true ro the best of my knowledge. �
<br /> Use a second sheet,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. t ( � ,,,,,,,,
<br /> J�-Pv.'n� �v-1�i�i� �4 �l`1 v �....alL o�a �'�
<br /> ' ensee Business Name Lic.or Reg.No.
<br /> --""'�`�"��a�, /if,.
<br /> �._,_... ¢��J
<br /> Cer i ied Representative Signat e Certified Rep.No. Date
<br /> L�CAL COPY 7 �2 E � E Name of Dri ler Y' t,/ �U�n��
<br /> ' IC 140-0020
<br /> HE-01205-12(Rev.12/08)
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