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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UN/QUEWELL NO. � County Name WELL AND BORING RECORD , � � ,� � ` g$�n�p�n Minnesota Statutes, Chapter 1037 7� � ; J t Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed orono 1181� 23w 31 Sw Ni� 5E 19Q tt xav 2, 2Q05 - ; i i v< GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ Longitude degrees minutes seconds � �,Cable Tool �__j Driven !��Dug �;Auger �Rotary �,Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� . � - R3SS CI1�p�eMS L8A!� Maple Plain DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact bcation of well in section grid with"X". Sketch map of we!I location. �t8� FROM ft.TO ft. Showing property lines, - N roads and buildings USE � �]Monitoring �Heating/Cooling ' � � Domestic ��Environ.Bore Hole � �Industry/Commercial �� --'--- ' -`-- --`— . � ;� j [y('�.. � � unity PWS �]Irrigatio ��Remedial � . � .f lr t'_ f�'��ir� r. oncomm n �. , , I ��-�Jv— __Community PWS [�Dewatering ❑ � � � CASING HOLE DIAM. ; w ; e _ ---- --_._ ._._. � -� � ,_ .� V DriveShoe? ��Yes �No � .: , , ._._..._ ��,�Steel . ;-_- - -' -�— T �- �. ._.... �J Threaded �W� d � '/Miie � �� Plaslic - - -- 1 �"` � - ; i :_� CASING DIAMETER WEIGHT S 'C.� 4 �,,.to 175 ft. IbsJft. o} �� 0�►0 n. ��nnne� eA in.to ft. Ibs./ft. 6� in.to �pvft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. W�� MCCF8C�I1 SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make gqC�__ FROM ft. TO ft. 4355 Chippewa �s$118 Type �� Diam. I'�4sple Plt3itl� 2Qt 55359 siouca��e__ ��__• �e�9m g; - Set between 17S__ft.and j�� R. FITTINGS � p�ker STATIC WATER LEVEL �v 8.j. below j_�above land surface Date measured a 1�Z�V5 PUMPING LEVEL(below land surface) ��g � WELL OWNER'S NAME/COMPANY NAME Wj.1.Y.�8i1 �CCiIAC��.12 ft.after hrs.pumping '�� g.p.m. WELL HEAD COMPLETION an Well owner's mailing address if different than property owners address indicated above. �Pitless adapter manufacturer �� Model ~ Casing Protection �'12 in.above grade r At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted f�Yes ��No Grout material ��,�Neat cement j�Bentonite ! ,Concrete [I High Solids Bentonite from IQ to �� ft 3 'J yds. �bags from to R i_i yds. J bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft I�yda ��bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATIOf��,et Sa' f r0�. S@TiIPY� tOp soil Zf�.SCtC Q ZQ teet _direction type Well disinfected upon completion Yes �]No Cl.e�y yellcnr 1� 'I{� PUMP �� I�Not installed Date instal�lerd �,� ClSy gTSq �� 1�4 Manufacturer'sname f�`?:��_� Model number HP t � Volts $gna � g18V@1 ��.�CCd �.�Q ib� Length of drop pipe 1 tF� , �'7 f/ ft. Capacity �� g.p.m. Type:r!Submersible �]LS.Turbine L,Reciprocating �]Jet �_j clap 6 granel red 1�5 �7Q ABANDONEDWELLS - n p Does property have any not in use and not sealed well(s) ��Yes � No sand r�� .7V LOQ VARIANCE Was a variance granted from the MDH for this well? ❑Yes �No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The informa�ion contained in this report is true to the best of my knowledge. Use a second sheet,if needed ?. REMARKS,ELEVATION,SOURCE OF DATA,etc. SC@V�IIB ��.LI.�Y1F'j at F..21V�rOLI�f!I1t81 .SV'C 8b654 Licensee Business Name Lic.or Reg.No. �. � -- _ , 1i- "`� -G�-� _ Authorized Representative Signature Date Randy Jehnson LC)GAL COPY � � �" ��s � /'� NameolDriller r 6 df IC 140-0020 HE-01205-OB(Rev 5/02)