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:�� --:.Y :,,�, _ -•- - . � ;� �,�. .. WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD- 5 9�. 5 3 H Henne in Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �rona lI7 2:i 33 SW,,.NW,. SW,, 1�5 n 4/2,t/9t3 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 75 Crystal Creek ��iit� Cl CableTool ❑ Driven ❑ Dug ❑ Auger ❑ Rotary ❑ Jetted Show exact loca6on of well in sec[ion grid with"X". Sketch map ot well location. ❑ .__ �� _ Showing property Ilnes, roads and buildings. DRILLING FLUID N '�`'� � � � � i�idL+�r -�- -�- -�- -�_ USE ❑ Monitorin � ' �AL Domestic 9 ❑ Heating/Cooling _i_ _�_ _�_ _i_ � �- �� ' ❑ Community PWS ❑ Indusiry/Commercial � � � � ��. ❑ Irrigation f � ❑ Noncommuniry PWS O Remedial w E (',�..Y(l� - ❑ Test Well � i i i ,j ��, ❑ Dewatering � -r -�- -r- -r T ' i � i i yzM1e ^ �, (,,�'� � CASWG Drive Shoe? ❑ Yes ❑ No HOLE DIAM. _� � _L_ _�_ � � ��L.t ...,y; ❑ Steel ❑ Threaded CJ Welded r -,- � � 1 � ; `�L �1 �Plastic ❑ �1 M�le--{ 1�,,..�,..-.�._. ..._.; CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME _�_in.to ft. ��Ibs./ft. 'x __�._ln.to `.�1tt. . MarK � Lauri� 5wumers ��.�o n. __�bs.�n ,� ,o i ti�. Property owneYs mailing address if different than well location atldress indlcated above. in.to fl. Ibs./fl. m.to ft. � C�O Lf3C� C��i�truction SCREEN OPENHOIE Make J�ayco from fl.to fl. 1��0 �l�ll�� Drive .C/t.e lV5 Type Y��. Diam. �iC�'G'Yl Prairie, MN 55349 SIoVGauze �Q _Length � � Set between 150 fl.and 1 5 ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME 4� ft. C�below ❑ above land surtace Date measured PUMPING LEVEL(below land surface) Well owner's mailing atldress if diBerent than property owner's address indicated above. �7 ft. after � hrs.pumping �� g.p.m. WELL HEAD COMPLETION ffi Pitlessadaptermanutacturer��llL�i�T2i�@t Mouel �-5-4 ❑ Casing Protection ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? J� Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� C Neat cement 1$Bentonite ❑ Concrete ❑ High Solids Bentonite MATERIAL trom 60 to 6 n. 4 ❑ yds.� bags d l 1 from__to ft. ❑ yds. ❑ bags ��dy vI'C3Wi7 til�C1. from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION "' Cldf �ij'uE.' �E.'a. ll '3� Q� feet � directio`r►�M�E.''r �l;��pe black/ Well disinfected upon completion? f�Yes ❑ No .°�i'$a'1C� ba Cld� j?.1t1�2 111@�• .�i3 11� PUMP ❑ Not installed Date installed 4/L 7/7 v St�iICP� C.Ldj/ Y7�.LT`'�.i' IC1�G[. �ll 143 Manutacwrer'sname K�� 33L4��__ Model number HP 1_�____ Volts l�� � �� Len th of dro i e_ m. sanrl b yravel ix �aur�e 143 155 9 PPP 1 �,� h Capaciry 19 g.p. Pressure Tank Capaciry Type�tC7 Submersible ❑ L.S.Turbine O Reciprocating ❑ Jet ❑ _ ABANDONED WELLS Does property have any not in use and not sealed well(s)? 0 Yes xE] No t .a VARIANCE ' Was a variance gianted from the MDH for this well? ❑ Yes �E7 No WELL CONTRACTOR CERTIFICATION Use a second sheef,il needed This well was drilled under my supervision and in accordance with Minnesota Fules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The intormation contained in this report is true to the best of my know�edge. RES Well Drillln� l71?6 Licensee Business Nam� Lic.or Reg.No. � � f �.. - �,._.�,:=� -� �� r . ��.ri : E .. , __.�, Authorized Representative Signature ate 1tot�rt E. SL�tlo3o, Jr. S/i/9t3 Name o!Oriller Dafe LOCAL COPY 5 915 3 8 HE-01205-05(Rev.1/95)