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<br /> WEL'L OR BORI G LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/N��G NO. ELL
<br /> CountyName WELL AND BORING RECORD - . -
<br /> Minnesota Statutes,Chapter 1037 ���� � � M1
<br /> Township Na Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> �� '/�� it.
<br /> GP DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds ._
<br /> Longitude degrees minutes seconds ❑Cable Tool , i Driven � Dug
<br /> Auger i�otary . �Jetted
<br /> House Numb,�r,Street Name,Ciry,and Zip Code of Well Location or Fire Number C �
<br /> 2J�J�t DL�IC�Cs �1(rt !W� Ot�c�nc 5391 DRILLING FLUID W[�CL HYDROFRACTURED? ❑Yes o
<br /> Show exact location of well/b ing in section grid with"X" Sketch m of well/boring location. ��� From ft.To ft.
<br /> howing property lines,
<br /> N .� roads,b �Idings,and direction. USE �omestic �J Monitoring ❑Heating/Cooling
<br /> __.___ __1__ __L____:_ ��'�p�y L�Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
<br /> _ yn /, �
<br /> ' ' ' ' ;.—�,4�.*� I—J Community PWS ❑Irrigation ❑Remedial
<br /> � � , , � ..�, ! .
<br /> -- -- Elevator ❑Dewatering ❑
<br /> v�/ E T �'� / � CASING MATERIAL � -- HOLE DIAM �
<br /> I l � � . Drive Shoe. j�(es ❑No
<br /> ,, �.� �Eteel �(fhreaded I]Welded
<br /> ' ; , 'F M�ie f�� r iamet stic Wei S hons
<br /> # �
<br /> , , , � , j Pla � __
<br /> --�--- --�--- --�—--�- � + �. . .
<br /> ; ; ; , CASING
<br /> 5 � �ii D� er 'ght pecifica�
<br /> 1 [� +� !y '�(�
<br /> �iMiie—� , '* in.to�.�j ..._ft�� Ibs./ft.�� � in.to��'" ft.
<br /> ♦ �
<br /> PROPERTY OWNER'S NAME/COMPANY NAME '` � ` in.to___.__ft. Ibs./tL _ � to�tt.
<br /> A._..�� � � � _ � " in.to ft. Ibs./fL ��t�ft.
<br /> LLliRf.
<br /> SCREEN OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. q�� �e�
<br /> _t Q�q ��� a,� � Make From � ft. To �� ft.
<br /> a�t�Ji� n
<br /> P��y�ti! L'i� �.79'Y7 TYPe Diam. - - -
<br /> 1""""` t SIoUGauze Length
<br /> Set between ft.and ft. FITTINGS
<br /> STATIC WATER LEVEL
<br /> Measured from
<br /> fL��� elow ❑Above land surface Date measured_�x'��__
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) .
<br /> �� ft.after � hrs.pumping � g.p.m.
<br /> Well/boring owner's mailing address if ditferent than property owner's address indicated above. WEL COMPLETION ��,� �—�'',4�
<br /> �itless/adapter manufacturer i i�`Yf��-t-1�-�`�'AFedEI
<br /> asing Protection_ _ _, __ ��'2 in.above grade
<br /> � ��Abgrade(Environmental Well and Boring ONLY)
<br /> e. GROUTING INFORMATION
<br /> Well grouted ��Yes [�No
<br /> Grout materials ,_Neat cement f�6entonite I��',Concrete ❑Other__ __
<br /> From__�To._�ft. ___._� �� '�Yds. � �ags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From,_�To�SS ft. ��, [�'�c�.,��,. i Bags
<br /> MATERIAL From To ft. " I Yds. i I Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> C� � �a� � � ��/ teet 1,�..3 direction
<br /> t� Well disinfected upon completion? �_ es �.�]No
<br /> C�I� �Cd� �OfL 9V I�S PUMP
<br /> I J Not installed Date installed �� • ' �—��
<br /> ��ti@ 38tIC� �!'8j► a0� Z�'� Z�
<br /> Manufacturer's name
<br /> ���a��� � �� �� ��C Model Number HP 1 Volts �r'
<br /> � / r
<br /> Length of drop pipe f�+.! K. Capacity g.p.m.
<br /> t j�„�,�� `� �� �1�"i)" �$S Type:��. ubmersible ❑L.S.Turbine ❑Reciprocating ���]Jet ❑
<br /> .xs�ri vza�wia
<br /> ABA ONED WELLS
<br /> Does property have any not in use and not sealed well(s)? ',]Yes ( o
<br /> VARIANCE
<br /> Was a variance granted from the MDH for ihis well? `J Yes o TN#
<br /> 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,il needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,eta .
<br /> T7an �Stodala HeII Dcilling, Ct>., ic�. 1b92
<br /> Licensee Business Name ' Lic.or Reg.No. �
<br /> ��'- �� . c� �
<br /> p en Si� ure� Certitied Rep.No. Date
<br /> LOCAL COPY ^���6 �� ����
<br /> Name of Driller
<br /> IC 740-0020
<br /> HE-01205-11(Rev.3/07)
<br />
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