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MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. Cchnty Name ' WELL AND BORING RECORD �, _ " R�YlE� in Minnesota Statutes,Chapter f03I � 5��q- r Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED Oror�o lI7 23 22 �� 290 � 11-8-07 r GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ❑Cable Tool ❑Driven [�Dug — ❑Auger �Rotary �]Jetted ' House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� c /�/ T n� �4lO 1518� vLdC� 55331 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in sectidr�qrid with"X" Sketch map of well/boring location. ��t�t� From ft.To ft. ti Showing property lines, N roads,buildings,and direction. USE �Domestic ❑Monitoring �_]Heating/Cooling �. I I I � . - . ' -; __,_____A________ ______ ❑Noncommunity PWS ❑Environ.Bore Hole �_J Industry/Commercial ❑Communiry PWS ❑Irrigation ❑Remedial �:: --�-----=------=-- ---=-- ❑Elevator ❑Dewatering W E �_— CASING MATERIAL ❑ HOLE DIAM. ' � , � � � Drive Shoe? '�Yes ❑No --:--- � ---�-- ---:-- T --.-- �� , , , , nniie stic readed elded h :�� S �h ❑W te ,- , , , � ❑Pla ❑ - � --�-----�----�-- ---�-- ' i ` CASING � S � \'1 � ��y� Diameter Weight Specifications t �1 Mile—� �in.[o_�_ft. _;�Ibs./R �_in.to�aft. PROPERTY OWNER'S NAME/COMPANY NAME in.to fl. Ibs./ft. �in.to��ft. l l.'lC3.s BOZi�.S in.to n. �bs.�n. I$to'��n. SCREEN OPEN HOLE Properry owner's mailing address if diNerent than well location address indicated above. 4/.Y, HM ZZQ StWW� uRp � Make G�f�4 67V From ft. To ft. .7 Type Diam. Long Leke� MN 55355 SIoVGauze Length Set between ft.and ft. FITTINGS � STATIC WATER LEVEL Measured from � ft. Below ❑Above land surface Date measured ��n7 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surtace) _�_ , ft.afler � hrs.pumping__� g.p.m. + � Well/boring owner's mailing address if different than property owners address indicated above. WELLHEAD COMPLETION �y�, � r Pitless/adapter manufacturer 1 � -`�,..--�-�-�-3'a-� — IOfodel ❑Casing Protection `6d�12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) r� GROUTING INFORMATI N Well grouted �Yes ❑No Grout materials ❑Neat cement�Bentonite ❑Concrete ❑Other From�To�ft. �_ ❑Yds. �ags � GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_�_To�tj��i[IJ�ds. ❑Bags - MATERIAL From To_ fl. ❑Yds. ❑Bags ; NEAREST KNOWN SOURCE OF CONTAMINAT� *: f' t-'1S U� !�� feet l direction _. .i� . �-�� J t e ' YP gr$�, Well disinfected upon completion? ,�Yes ❑No > $li� L• a PUMP .. / ) � 1 '� ❑Not installed Date installed �-�J �'1 'f' C� Manufacturer's name - �-�`�- ��'�'��""' C�a!/� p�J• Model Number �HP � Volts �� -�,�--� Length of drop pipe /�-�� ft. Capacity g.p.m. ceddish �� Type:�_ ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS rea.ai$r, � Does property have any not in use and not sealed well(s)? ❑Yes �'No VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# - � 4 WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Stodol8 Well Dcil2ing Co., Inc. 1692 Licensee Business N e . Lic.or Reg.No. ti...�"'� � ' �' �� �.--�� ., /,�` �;,1::J -<., I e ied Representative Signature Certified Rep.No. Date LOCAL COPY 7 5 0 6� 4 J� �� Name of Driller IC 140-0020 HE-07205-10(Rev.6/O6)