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MINNESOTA UNIQUE WELL WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORD 7 4 3 4 3 5 �erm�pin Minnesota Statutes,Chapter 103I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED ' 4ccx�o II7 23 10 .,, ,,a ,,. 176 n 2-22-47 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds �. I�Cable Tool I I Driven �.Dug Longitude degrees minutes seconds Auger �Rotary Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � . 920 Bro�m Rd S, VrOYIO 55356 DRILLING FLUID WELL HYDROFRACTURED? I.;Yes No Show exact location of well/boring in section grid ith"X." Sketch map of well location. �j'itflj�i te From ft.To ft. Showing property lines, 7 N � roads,buildings, � �Monitoring IJ Heating/Cooling �� ; ; ; ; and direction. � Noncommunit PWS �. Emiron.Bore Hole I �.Industry/Commercial - ' --'--- --'--- ---`— --'-- � t omestic i , i i i i . . mu y WS . . i � � emedial Y � CASING MATER ALnrt D��IrrigaCon ' '�R � P --;--- --,- -,--- ---;-- � Threaded 9,Ye —Welde 1, ' W � 1 � E T eel L I d OLE DIAM. r s ' H . , , �1St � � , � �( --�--- --'----�-- --`— - � /"7 Plastic ❑ _ '/,Mile ; ! i ! I CASING ----- --'----•-- ---•-- � � � 1 Diameter Weight Specifications ' S � \\ t �—1 Mile—� ��u' � in.to �� K. ��oa Ibs./fL � �L ,in.to �t ft. in.to _ _ ft. IbsJft. D�in.to�1U ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs.lft. in.to ft. StOT�O� ��p-- LE �� iti,I�+ SCREEN_�____ OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make From _ ft.To _ft. � 7407 Wayzata Blvd ��c��ess st� Type _. � _ Diam. `: �- �7� i.R7�7.i..a �r� r�N SSli2b Slot/Gauze t�}L•v�� p Length_ 4 .. �� � i Set between�ft.and�.�) fl. FITTINGS�� * � STATI ATER LEVEL�/ q � �` �� ft.,L^4 Below I '��Above land surface Date measured. . �+`�� PUly1P�LEVEL(below land surface)�. WELUBORING OWNER'S NAME/COMPANY NAME 1____.______ft.after � hrs.pumping � g.p.m. � WELL HEAD COMPLETION t-! '�'• ``�yy�,� ,� Well/boring owner's mailing address if different than property owner's address indicated above. �pitless Adapter Manufacturer L)--��"""�—�" - — Tvlodel _ � i�_!Casing Protection �12 in.above grade CAt-grade(Environmental Well and Boring ONLY) t i GROUTING INFORMATION.� Well grouted? ,��°Yes C No y � Grout materials . .Neat cemery,A�Bentoryjj�. .'��.Concrete �.Ot�r ____ �, "' From �'� To "Xj ft. �.r Y=d*s. �Bags ��. From�� To��ft. �� .J1�di�O Bags " GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__ To ft. I I Yds. f.7 Bags MATERIAL -- NEAREST KNOWN SOURCE OF CONTAMINATION � .j`-� �... .A..-� 3 Ci�y�.�� b� .�Qf� h �f�f feet _direction � �� _type x � �� Well disinfected upon completion? � Yes ❑No * t PUMP � Caa� � ��t � "� '�..I Not installed Date installed ��' ��^�`'� � C18 br{7�J[I $Q�t yo � Manufacturer'sname ��"'"^—' ' �" �tC7 Model Number HP � �� Volts �fl - � ' $$j� � �ft � 11Q Length of drop pipe � � ft. Capacity g.p.m. Type:'�.Submersible ��LS.Turbine '��.l Reciprocating I..I Jet I 1 ei� b�Q� ��t$}� �IO 2� ABANDONED WELLS Does property have any not in use and not sealed well(s)? �.:�Yes Y?No `� s$ju/ �0�� bt�l �}i r 1{W 1�(7 VARIANCE Was a variance granted from the MDH for this well? C Yes�No TNk �' c WELL CONTRACTOR CERTIFICATION 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 knpwledge. Use a second sheet,if needed. : REMARKS,ELEVATION,SOURCE OF DATA,eta a�t�ii Stodola._�1�Dti1. Ib9i �L� Ca.. �. Licensee Business Name Lic.or Reg.No. - �� " ..��- `� G� i presentative Signature Date R1�1!`1[ M(1t11'A LOCAL COPY 7 4 3 4 3 5 Name of Driller HE-01205-09(Rev.9/O5) IC 140-0020