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, , .� �., : _ °�! ,�-,,,�„ WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD � 61 �J 5 �J 2 �3�nnv�I TI Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed fl. orono 117 ?3 U9 ,�. �, ��. 1�J0' 6-3C?-98 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD i�40 BOh�1'S Pt RG� Urs�na, ?� � `"`' ❑ CableTool l7 Driven ❑ Dug • • • '�'�3�� ❑ Auger �7 Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ Showing property lines, - roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �NO N i i � i �2��.�3ll�t� FROM ft.to ft. _i _i_ _i_ _- USE O Monitoring ❑ Heating/Cooling � i i i i Domestic � ❑ Community PWS ❑ Indust /Commercial i � � i ❑ Irrigation ❑ Noncommunit PWS ry w E T �, ❑ Test Well y ❑ Remedial � i i i I � ❑ Dewatering ❑ -r -�- -r- -r t� i i i i �/ZM.1e L CA91NG Drive Shoe? ❑ Yes '�i No HOLE DIAM. _i_ _ i _i _ _i_ �- ❑ Steel ❑ Thread�l�� ❑ Welded � �- � � 1 � (� � Plastic ❑ F—,M��e—� �O f��!5 �" � � � CASING DIAMETER WEIGHT PROPERTYOWNER'SNAME 1� in.to�_ft. ],�� Ibs./ft. � in.to �t�ft. t�"��yl,r��s� � �� r�r�y�r�� I'�� in.to ft. Ibs./ft !/�_� . t Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. 3 E3 2 O S� f��Y� �� SCREEN OPEN HOLE ��I�+t��it7� a�• 5539I Make • from ft[o ft. Typ��3 t1t]_��C �t�el Diam. M SIoUGauze r��f� Length �� Set belween ft.and ft. FITTINGS 7�► � S�d N �`j �} STATIC WATER LEVEL , WELL OWNER'S NAME �� tt.�below ❑ above land surface Date measured Fi.��(1.�. $ PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. �� ft. af[er ��'i hrs.pumping �(�1 a i r g.p.m. WELL HEAD COMPLETION .�i7 Pitless adapter manufacturer Model '�LJ Casing Protection �1 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMAvTION Well grouted? L.xLYes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete Q(High Solids Bentonite MATERIAL from ro ft. ❑ ds. ba s —$— �� .�— Y � 9 from to ft. ❑ yds. ❑ bags F]'.11 RrGut� S C?f � from co n. ❑ yas. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION : � y'T'(,s ��PiCa ��C1WII � � � �L� �j�f feet �t'.�LI�� direction ��_f�type Well disinfected upon completion? ❑ Yes ❑ No ��G�� C��3� S%li1Cl �rGSWTi S G{� �U PUMP ❑ Not installed Date installed ��1��7 p Y"��r �`'3'Z�` Gray � �� z�� Manufacturer'sname tt8�'. Jacket Model number Q 113 8�4 HP�_ voiu 2 3 0 - Length of drop pipe �3 __ ft. Capacity 1� g.p.m. Type: f?Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet L7 ABANOONED WELLS y' � Does property have any not in use and not sealed well(s)? ❑ Yes Q-No . VARIANCE Was a variance granted from the MDH for this well? ❑ Yes [.�No WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The in�ormation contained in this report is true to the best of my knowledge. DON SI'{3DQF3A WFI.�,LDRILLI�IG C0. , I�tC. �� s� " Licensee Bu "ness Na : Lic Reg.l�lo��g "";"'^ 1� � � �r S Autho¢ed Represerf(eti✓e Signature . '� Date ��2i1C?{ I`�C?QI2 ��-��—�$ Name ol Driller Date LOCAL COPY �15 5 5� HE-01205-06(Rev.9/97) �