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� � � --- MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. CountyName WELL AND BORING RECORD � �. Minnesota Statutes,Chapter 1037 - � ��`j �� Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED /. '/< �.`�� n —l�� GPS � ` � " DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds [i Cable Tool ❑Driven � Auger �otary House Number,Street Name,City,and ZIP Code of Well Location [�Other 2`^rSE! C�RS!ICLyS�� i�.� vL�OI�O 55355 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X' Sketch map of well/boring location. From tt.To ft. Showing property lines, N roads,buildings, nd direction. USE �f,omestic !�Monitorin ,Jx��, g ❑Heating/Cooling � _:___ __1__ ___L__ ___:__ ❑Nonwmmunity PWS ��l Environ.Bore Hole ❑Industry/Commercial �� ❑Community PWS ��Irrigation ❑Remedial � --'--- --'--- ---`-- ---`-- ❑Elevator ❑Dewatering ❑ ' ��: '�'� ; , , ; E CASING MATERIAL Drive Shoe? �]Yes � No HOLE DIAM. � � T � --.-- --.--- --�----.- , ' �� ❑Steel ❑Threaded [�Welded �J � � � � Mile 1 O D amleter Plastic L 1 � --�-----�-----�-----�-- .� g � �, Weight Specifications .11 ' r` F-1 Mile� �•:--t_;.. -, ?•,_.,--,� ?-�.. �,/a.. —4—in.To_�ft. Ibs./ft. _�in.To G n_ft JZ7 PROPERTY OWNER'S NAME/COMPANY NAME in.To ft Ibs./ft. �;_in.T(i_��ft �,,�^ 4 Iarrisne Kr�tC+A!Kin in.To ft Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make � From ft. To ft. �c'31`r7� S�$ T! @S$ �tf.'�'e Diam.� Type_ SIoUGauze Length Set between �ft:an ft. FITTINGS STATIC WATE C L X � Measured�rom �j� _fL�3elow �]Aboveland surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �7� n ft.after � hrs.pumping �`� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION � [�Pitless/adapter manufacturer ��t�� _ Model ❑Casing protection �r 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUTING INFOFIMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) - Material>>,.,.�cin3i«From n To�ft. � ❑Yda �Bags —�T Material�_a�i�prp�To�ft. ❑Yds. ❑Bags S I HARDNESS OF Matenal From To tt. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION to�soil hlack PrT@C��1$Ti � � _ � (� feet F� '—'J direction �. �.s type L Well disinfected upon completion? es []No 3�[lCj�i CZ$� s.7LOWi} T�ICIL'�'1 �I �,fj PUMP ❑Not installed Date installed ��a�.�.(F ga�y C��y ''L'� �d�� 12� Manufacturer's name :iC�'1€f�f(?j" Model Number HP 1.5 Volts �3� s�nc1/clay �•ra r�it�m 1?� 14'.-3 t G Length of drop pipe i�(�' ft. Capacity g.p.m �Cl�� C1$� r� ,„,�� I�n �� Type;,�Submersible [�J LS.Turbine ❑Reciprocating ❑Jet ❑ sttC^! � ABANDONEDWELLS ��/Lsl$� �ra. _,,,�a�j� ��f_ �� Does property have any not in use and not sealed well�s)? ❑Yes .�No ' �dK:IA sf F VARIANCE '�'�K�,7 ��,� ceddish P.�dir� i 75 1�(� Was a variance granted from the MDH for this well? ❑Yes � No TNIt WELL CONTRACTOR CERTIRCATION � This welf 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 knowledge. �AV�t Use a seco�t,il needed. L`QLjr$e �� REMARKS,ELEVATION,SOURCE OF DATA,etc. t)an Stodola �de21 �cilli = Co . Licensee Business Name Lic.or Reg.No. � /' �`� � � Certified Representative Signature Certified Rep.No. Date j P,ob Stodola " 4�,� �'��4 � �OCAL GQPY � _ ." �,.F Name of Driller IC 140-0020 - � � HE-01205-14(Rev.5/12)