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MINNESOTA UNIOUE WELL WELL OR B R'iING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. co��ry Name WELL AND BORING RECORD � � �6 �5 �TR]e �n Minnesota Statutes,Chapter 103I Township Name � Township No. Range No. Sa�tion No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED a Ora� 1!7 23 ': 09 �, �, ,,, I08 tt 22-4-07 GPS �-� �' DRILLING METHOD �- LOCATION: Latitude degrees min "s seconds Longitude degrees mi ''tes seconds ❑Cable Tool ❑Driven ❑Dug -- j]Auger �]Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Lo ��ion or Fire Number � 1540 Bohns Point Rd O� S�J7� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section ith"X"�� \�Sketch map of well/boring location. �(it�i=e From ft.To ft. t` ' Showing property lines, N b��' roads,6uildings,and directioa USE �Domestic I]Monitoring ❑Heating/Cooling - __j__ __y_____�____,__ � ❑Noncommunity PWS L]Environ.Bore Hole ❑Industry/Commercial �' � ❑Community PWS L�Irrigation ❑Remedial �)\ ,�Elevator [�Dewatering � w e \� CASING MATERIAL Drive Shoe? ❑Yes �f No HOLE DIAM. - --�-----�------�-- --.- - - T \ � , , , ❑Steel �]Threaded ;]Welded `, , � '�_ '/�Mile �PI � - -- -- � �,� astic CASING S � Diameter Weight Specifications �—i nniie—� �_in.to�fl. � �_IbsJR. &�9ttA �in.to_�ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. � Ibs./ft. _ �.in.tolOHft. �t��w� *T n in.to _ft. Ibs./ft. in.to ft. �R,1U.� irlti OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 7�Q/ n8�ta Bl�� Jte LW Taee FroDiam. ft._To ft. I�icmea lis I�At 5542b yP - -- 4 � � y� Sbt/Gauze A7 t\ Length (+�_ �.__I.�I Set between ft.and ft. FITTINGS STATIC WATER L Measured from � ft..�Below ❑Above land surface Date measur� � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) - IQ� ft.afler 1+5 hrs.pumping �5 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION - {.. �Pitless/adapter manufacturer l�}-�,��w.,_1Q�7,0.�. Model Casing Protection �12 in.above grade ❑At-grade(Ernironmental Well and Boring ONLY) GROUTING INFORMATION �� Well grouted �}Yes ❑No Grout materials ❑Neat cement �Bentonite�❑^Concrete ❑yOther From �n� To .�1 ft. -7 ❑Yds. �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From JV To 7v fI�SLLICSl l�J�ds. ❑Bags MATERIAL «-! p From�To�ft�avC 1__��ds. ;�]Bags NEAREST KNOWN SOURCE OF CONTAMINATION .�. �18 t8 9(>fC 0 60 !`, ' � ., _� ,�.._ _ ;:�,s<._ ,.�_ feet direction _. .y �''type � Well disinfected upon completion? �Yes [j No �,-r...��` .3�--+�"' -%� 1�XiA1 SOl t � �O� PUMP � ❑Not installed Date installed - � ' Q Manufacturers name ��-- � Model Number HP � �a Volts �� Length of drop pipe �j�ft. Capacity g.p.m. Type: Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABAN ONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes �No VARIANCE Was a variance granted trom the MDH for this well? ❑Yes �No TN# WELL CONTRACTOR CERTIFICATION t 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 sheeG if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodol.a �I1 Drilling Co., Inc. 169I Licensee Business Name � Lic.or Reg.No. �.� �'. .,�' _._.��'- �..3-4� ifted Representative Sign-�ure� Certified Rep.No. Date C �� LOCAL COPY 7 �,O 6� .J - -- Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6) � M1