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MINNESOTA UNIQUE WELL <br /> ELL Uri G LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD - . V <br /> f <br /> Minnesota Statutes,chapter 103I 9 1 3 & <br /> Township Name Township No. Range No. Section No. Fraction(sm. lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> ft. <br /> '/ '/4 'L. <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude_ Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger ❑Rotary 1 j Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes E`No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. / "f'0 n 4 '" From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings and direction. USE Domestic ❑Monitoring ❑Heating/Cooling <br /> I 1 1 <br /> L El Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> _ 1 <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> �___ ,___�___,__ ❑Elevator ❑ <br /> W E-. CASING MATERIAL Drive Shoe? ❑Yes (j No HOLE DIAM. <br /> T r I [ Steel ❑Threaded ❑Welded <br /> 1/2 Mile ❑Plastic ❑ <br /> i - I CASING <br /> Diameter Weight Specifications <br /> S <br /> 1 Mile I in.To ft. lbs./ft. in.To 5 0 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME _ in.To ft. lbs./ft. n.Toft. <br /> in.To ft. lbs./ft. in.To ft. <br /> brina ►:1leCk <br /> Property owner's mailing address if different than well location address indicated above. SCREEN Ye s OPEN HOLE <br /> Make Johnson From ft. To ft. <br /> Type s t a i n l e ss' s Diam. <br /> Slot/Gauze ' �y Length <br /> Set between 2 00 ft.and 2 10 ft. FITTINGS lead <br /> STATIC WATER LEVEL ft. ❑Below ❑Above land surface <br /> Date measured 9/2 7/2 3 Dry hole ❑Yes ❑No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after 2 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 monitor bu l IMod`el <br /> ❑Casing protection ❑12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material Cut t i n ;From To ft. ❑Yds. ❑Bags <br /> Materialh e fl t O n t From To ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL Driven casing seal From To Bags <br /> One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Ia' Well is _ feet direction from type <br /> Well disinfected upon completion? ❑Yes ❑No <br /> lay PUMP❑ .Not installed Date installed /2 8/2 3 <br /> a n y Clay ;.'ray Manufacturer's name <br /> L'" <br /> Model Number HP Volts 2' 1 1 5 <br /> -7,and Brown 3 Length of drop pipe ft. Capacity g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> -.Tine Sand Bro :) ABANDONED WELLS <br /> Sine Silty <br /> r Does property have any not in use and not sealed well(s)? Li Yes Li No <br /> San .J Clay Gra.yL. 14( t.. VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes ❑No TN# <br /> "'Gray. ,S _L 94 ?' i 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 /> ,7 ^tod.ala Uell DrillinL Co <br /> Licensee Business Name Lic.or Reg.No. <br /> 'N---- --.'t/ f.,el- <br /> . ... <br /> . . <br /> Certified Representative Signature Certified Rep.No. Date <br /> 'oh Stod.ola <br /> LOCAL COPY <br /> Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />