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MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. coon Name WELL AND BORING CONSTRUCTIONTRECORD J 5 4 Minnesota Statutes,chapter 1031 Township Name Township No. Range No. Section No.; Fraction(sm.—.1g.) WELUBORING DEPTH(completed) DATE WO K C MPLETED ` Oro o 1t1 23 Id .7 5e N�� n. 1� �ti� '? GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD F. Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger "®Rotary ❑Rotasonic t House Number,Street Name,City,and ZIP Code of Well Location ❑Other IW 6 1--et JE.v ie w AV� Or U ylo 55 3r 1 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes TA No Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. b('f)�Uy�) I€-- From ft.To ft. Showing property lines, N roads,buildings,and direction. USE v Domestic ❑Monitoring ❑Heating/Cooling I I I _J___1_ _L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial 1 __ ❑Community PWS ❑Dewatering ❑Remedial ❑Elevator ❑ r W E 9CASING MATERIALShoe? ❑ HOLE DIAM. c Drive Yes No 4 r T ❑Steel ❑Threaded ❑Welded *4 '/Mile ,+'' Plastic ❑ - I CASING s _ ---- Diameter 1 Weight Specifications I 1 Mile X 4 in.To i 5 ft. lbs./ft. !J in.To50 ft. „ PROPERTY OWNER'S NAME/COMPANY{ 1 NAME in.To ft. lbs./ft. 7 i(L in.To' a ft. Je tr\n 1 (p y-. t o v 3 in.To ft. lbs./ft. in.To ft. tt SCREEN � 'S OPEN HOLE Property owner's mailing address if different than well location address indicated above. { Make i D Y‘i1 St)NI From ft. To ft. Sa Type 51G t')'1 1'C.S Diam. y Slot/Gauze I© Length X Set between I 1 5 ft.and 12 5 ft. FITTINGS t F'C"i_t e STATIC WATER LEVEL I'j I ft. 1.Below ❑Above land surface L ,4 Date measured 'Z Dry hole ❑Yes ❑No WELL OWNERS NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after z hrs.pumping 5Q q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION {A t� Pitless/adapter manufacturer t'1 U 11 r O/ Model ❑Casing protection X12 in.above grade „ •„ ❑At-grade ❑Well House ❑Hand Pump GROUT.INF``O,RMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) ,- Material..U tC 1 t• From 1,S To 5J ft. 3 El Yds. ❑Bags Material 12)eilf1Y111--- From ��-' To ft. ❑Yds. ©Bags HARDNESS OF Material From To ft. El Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite t NEAREST KNOWN SOURCE OF CONTAMINATION CAI``L1 �e . E \11 -1 \ `j i'\ r\ S 0 ;1 lad Cl1� i �fi c i Well is feet direction from type S DLt -1.1L!i j Well disinfected upon completion? ' Yes El No C. (ti ��Y�� it PUMP C9 a. rr,� LIB ( r' ❑Not installed Date installeda(� - C \ 6 1 C.t (l...f , - yt i - I Manufacturer's name v S C.- I .1 - � Model NumberHP Volts i kr `� 1 ] �' � V Length of drop pipe t-. ft. Capacity I g.p.m. ,9,j Type:XSubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ I ABANDONED WELLS •( 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 XNo TN# I i WELL CONTRACTOR CERTIFICATION I _ This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. a The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. 1 REMARKS,ELEVATION,SOURCE OF DATA,etc. } 11 S-0(L\& \NQk1 -i ,}.1111() 1 tot) t Licensee Business Name Lic.or Reg.No. j ": 7/..'"' ' '''''e!," ,. -a,'po'-' 11 \. L.I. . ' il Certified Signature Certified Rep.No. Date € i LOCAL COPY 8 7 3 5 4 9 Name of Driller 1 ID#52603 ' HE-01205118(Rev.3/19)