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MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. Ce�nty Name�� WELL AND BORING RECORD Minnesota Statutes,Chapter 103I �5'l��4 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED v< v< v< 1�! n (.�"13"'Q7 GPS DRILLING METHOD LOCATION: Latitude degrees __ minutes seconds ❑Cable Tool ❑Driven ❑Dug Longitude degrees minutes __ seconds __ I Au er �Rotar � � g � y ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � � s DRILLING FLUID WELL HYDROFRACTURED? ❑Yes�Na Show exact location of well/boring in s tion grid with"X" s �1 map of well/boring location. �t�ite From ft.To ft. Showing property lines, � :i N �r6�,buildings,and direction. USE �Domestic 'L]Monitonng ❑Heating/Cooling ,� __j___ _�____�_____L t ❑Noncommunity PWS j�Environ.Bore Hole ❑Industry/Commercial � 1 _�, j ! L i � �%` ❑ ommun y WS �Irrigation ❑ emedial , C it P R ,: , --;---- , - , L, ❑Elevator �Dewatering ;;. w , , , ; ET�� °�` CASING MATERIAL Drive Shoe? ❑Yes �j� HOLE DIAM. � --;--- --�----F—--%-- �� I � . ��'�''� ❑Steel ❑Threaded ❑Welded ...- � � , � Mile � � , , , , � ��' � �`i f�'�Plastic ❑ �• --�--- --T----�-- --�- � -' �% CASING � S � -�=� Diameter Weight Specifications - F--1 Mile—� � �in.to��ft. �_Q Ibs./ft. �!� �in.to '�ft. %':'�*-� . PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.t�.g1�ft. Tt�/Lpr�et te �rI18� in.to ft. Ibs./ft. in.to ft. �� SCREEN OPEN HOLE ' Property owner's mailing address if different than well location address indicated above. g�� a� gt�� Make From ft. To ft. ..r�.7.. UUYC � Type Diam. t SbtlGauze p•� Length � ';' Y* 10't �ft. FITTINGS � � Set between ft.and STATIC WATER LEVEL Measured from 3� ft. Below �j Above land surface Date measured �� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 17� ft.aRer 1.J hrs.pumping �� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer�.l��- �-= � ""'��nJlodet� ❑Casing Protection �2 in.above grade �� ❑At-grade(Emironmental Well and Boring ONLY) GROUTING INFORMATjON z Well grouted +�Yes ❑No Grout materials ❑Neat cement�(Bentonite ❑Concrete ❑Other From�To�R _� ❑Yds. �n Bags - GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�To��_n$�j]�_,��x�]Yds. ❑Bags MATERIAL From�To ❑Yds. g Bags NEAREST KNOWN SOURCE OF CONTAMINATION �j ' � feet direction - ' -� �'type � ' Well disinfected upon completion? f�7j Yes ❑No ,;.� _ t__.�---':-._-��- c�._ PUMP � ra ❑Not installed Date installed � f <� � � 11� Sf�t�`�� ft � �'1Q3 1ltJ Manufacturer's name — i�.... ^' i'�'' "--� ! Model Number � HP�Volts clay/rocks gray �i� 1S0 176 - Length of drop pipe �/G—� ft. Capacity g.p.m. � �/gr�� l �ft 176 10(} Type: , Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABA DONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE i Was a variance granted from the MDH for this well? ❑Yes No TN# 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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Dcm Stodole Wel2 Driiling Co,. Inc. 2691 Licensee Business Name Lic.or Reg.No. i -- ,> /--� /�� <� ertified Representative Si na e Certitied Rep.No. Date t�ck i�t�e LOCAL COPY 7 5 0 6 6 4 Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6)