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. '� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTN MINNESOTA UNIQUEWELL NO. <br /> CountyName WELL AND BORING RECORD 6 8� ��1 y <br /> A Minnesota Statu.es Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � . . Date Work Compteted <br /> ,, ,, ,, 190 " 2—I4—Q3 <br /> . GPS DRILLING METHOD <br /> " Latitude degrees minutes seconds <br /> LOCATION: -- � - �_Cable Tool �]Driven ' ��.Dug <br /> Longitude degrees minutes seconds �-��Auger �Rotary �_'�Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ��� � <br /> DRILLING FLUID WELL HYDROFRACTURED? �Yes �� o <br /> Shop exact location of well in section rid wit "X", Sketch map of well location. �j$t�� FROM ft.TO ft. <br /> Showing property lines, - - <br /> roads and buildings USE �.�,Monitoring i_',Heating/Cooling � <br /> + N ; " �- � ��No community PWS ;_ <br /> s � , , I <br /> -I Environ.Bore Hole i Industry/Commercial <br /> ' --'- -�--- `"` � Irrigation ' !R d I <br /> ' ;--- ; - ---�- � _ �_ eme ia <br /> ' , � I <br /> , Lj Community PWS Dri eeShoer'n9 - Yes N <br /> ' '- '"" '` HOLE DIAM. �� <br /> . l CASING � �� <br /> w ET _ o <br /> � � �� � i Steel ��'Threaded ❑Welded <br /> s, �� �4 Plastic i.� — <br /> � , , MI <br /> � -; � -.- l -°� •�-,� <br /> --,---- �---s-:-- - :: <br /> CASING DIAMETER WEIGHT <br /> `t��� _`f_in.to �S Z__it. ��Q�Ibs./ft. � in.to__�Q[. <br /> F--i Mae—� 1 <br /> .. in.to___ ft. .__.__ _Ibs./ft �in,to1QQt. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to___fl. <br /> teiner � Rop�e2man SCREEN_ ___ _ OPENHOLE <br /> Property owner's mailing address if different Ihan well bcation address indicated above. Make_ �Q�na�QjL-g S�_� FROM fi. TO ft. � <br /> 83G0 Minnetonka Blvd t i�lie� --- �--- , ,--- <br /> � Type _ _ _ Diam. � <br /> '' syza t s, MN 5 5 391 S�o�GaUZe •�1� �e�9th 4 __+_4 ___ <br /> p �f « � <br /> - ----- — — <br /> Setbetween�SQ._ ft.and 1�L ft. FITTINGS.�.�3Q�j <br /> : ST�TI�V�(ATER LEVEL �_*�—O� <br /> U _ 1 � <br />'����- ft.� �below 'above land surface Date measured_.___._—_. --..__ �: <br /> PUMPING LEVEI(b ow land surface) <br /> � WELL OWNER'S NAME/COMPANY NAME <br /> 1 79 ft after �___. hrs.pumping__3�_ g p.m. <br /> WELL HEAD COMPLETION ,.,.},�,� <br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer_w►!1_��Q���_�_ Model __._ <br /> _ �Casing Protection ___.____. �12 in.above grade <br /> -;At-grade(Environmental Wells and 8oring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted �Yes [�No <br /> Grout material �__,Neat cement �]Bentonite ` �Concrete�i High Solids Bentonite <br /> from�__to_��fL __�_ _ �..1�yds. �bags <br /> from_.�.___ro�_Q.�__ft.��(1.�'.�� �'--iy�s��'bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from__._ lo ft. _'�.yds. i J bags <br /> MATERIAL — -- ---- <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> . .� ;�., �.... ,- y <br /> lSy o�an oft fl i6 --1 � —feet =:� direction `�.-�-� ;:x` .�.�+�-,Lype <br /> Weli disinfected upon completion �Yes �.J No ::�;>"r-r <br /> 1Sj�' LEly Of t 16 gQ PUMP <br /> �Not installed Date installed 2����__ <br /> 8nd COWn �f t (�� 1 10 Manufacturer's name __ . _ _ <br /> � a <br /> Model number � H�r�_Volts <br /> Z$y r$y Of� 11� 1 30 Length of drop pipe _�4.�. ft. Capacity g.p.m. <br /> Type: Submersible 'Li L.S.Turbine �J Reciprocating [;Jet i=; <br />�� aQd ray � oft 130 190 ABA CONEDWELLS <br /> Does property have any not in use and not sealed well(s) �j Yes �No <br /> � VARIANCE . ' <br /> Was a variance granted from the MDH for this well? =,-'Yes �No TN# <br /> WELL CONTRACTOR CERTIFICATION � �^ <br /> This well was drllled under my supervision and in accordance with Mlnnesota R��les.Chapter 4?25- <br /> � The information con[ained in ihis report is true to the best of my kno��,�ledge <br /> Useasecondsheet,i/needed �j� S`tOd�la ���1 Dcillin,� Co. , Ine• 2 172 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> � -. _ ._---- ---------- ----�----- -- _._ ____.— . <br /> Licensee Busmess Name Lic.or Reg.No. <br /> - - :yT�� _ ---3'..20_{}3 <br /> h d enfaGve Signatw Date <br /> Chuck Moore 2-14-�3 <br /> ____ _ __ <br /> --- -- - -- - <br /> (� ����� Name of Dniler � Date <br /> LOCALCOPY � <br /> HE-01205-08(Rev.5/02) <br /> IC 140-0020 <br />