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� : S WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. � County Name WELL AND BORING RECORD �— c� g � � � _ i -J � � �' - ' ` Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � :�� :f ii . i� '? � ` � 1- 1 �. . �. �. �. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILUNG METHOD � ;c � ,_�_�, • .,�,: , ❑ Cable Tool ❑ Driven ❑ Dug ' � �-` ' " - -' � �� - ' ❑ Auger ❑ Rotary ❑ Jetted Show exact location of well in section grid with"�;". Sketch map of well location. ❑ � � Showing property lines, . � roads and buildings. DRILLING FLUID r N J��?-��.� . _ - I I 1 I __ __' ___ _I ... ' USE ❑ Monitoring ❑ Heating/Cooling i i i i i O;Oomestic _i_ _�_ _a_ _i_ ��'.� �.r-'� �-`.5'�s. ❑ Irrigation � Community PWS ❑ Industry/Commercial �-- i i i i � - � O Noncommunity PWS ❑ Remedial � w E ❑ Test Well i i � i T -H-�_-�� . ❑ Dewaterin9 ❑ i i i i I ' CASING Drive Shoe? ❑ Yes Q-"No HOLE DIAM. '/2 Mna _�_ i _L_ _i_ � ' M � ❑ Steel ❑ Threaded ❑ Welded � �' � � � �_._ 4,�lastic ❑ S �` f--lMile� `�..,4 -- CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 1 � in.[o ft. � Ibs./ft. %u�(t0� '�h. � a �_� c.,� ..,. .. ..... _..-�1. .�_'_ — : ; ;• in.to Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R y—in to tt. SCREEN OPEN HOLE t. . ._ . i i i_�. 1 .. .. .. . ,`i i--.._ Make .��✓i=I:e.._-r i�i from ft.to it. ' �.>, ,� .. . _, Type t::�-y ' i' �� Diam. ' SIoVGauze �i y '� (' Length " Set between � - ft.and � '''� R. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME � ft.b below ❑ above land surface Date measured �'-' � ' r PUMPING LEVEL(below land surface) Well owner s mailing address if different than property owner's address indicated above. ft. after_ ✓. hrs.pumping _ g.p.m. WELL HEAD COMPLETION ❑,-Pitless adapter manufacturer i:.��i�•� - a��_ --�1�Aadel ❑ Casing Protection CL�2 in.above grade ❑ Ahgrade(Environmental Wells and Borings ONLY) GROUTING INFOFMATION Well grouted? Cl.Yes ❑ No HARDNESS OF Grout Material � Neat cement ❑ Bentonite � Concrete �7 High Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ; � from to ' ft. ❑ yds. � bags from to ft. ❑ yds. ❑ bags `'c,t � � f. r,r 1,�c`�. -; 3 from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION � -:�; i ,_ x. - i � feet �-� ' direction � fi rype Well disinfected upon completion? O_Yes ❑ No � - :;i;6_./ . 3 ' l. ! �.l' i- • t ,: �UMP ��2��7 ❑ Not installed Date installed :' ;, . Manufacturer's name ��2�'�1 t Q ' `�1"F'' f � � , .Modelnumber 1 f1D/.ilfl') 7.r11�1 HP��Volts ''�y Length of drop pipe (t. Capaaty � Pressure Tank Capaciry_T(,''i zZ ��a�1 en�r Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes Lf No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes O�No WELL CONTRACTOR CERTIFICATION - Use a second sheet,ilneeded This well was dnlled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. 7he information contained in this report is true to the best of my knowledge. . . _ ! _ , . ,,..._ � .. � .. .. • s _,.. _ , Licensee Business Name �, Lic.or Reg.No. '... � ;�-%',r .� / ,�'`/�" �-=�—�1..: 1- . Authorized Representative Signature Date � ^ i ,_ �i.. _ .. .. � i � s, , � NameolOnller Dafe �� .: "_ � � � . � . �'' �'� �"`� �''6 � HE-01205-05(Rev.1/95)