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V I WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. ; �o��tYName WELL AND BORING RECORD � 8 � 5 � � Rennepin Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � OtOAO �i$ Z3 3�. ,, �. �. n House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 62S Deborah Lr� �r�n0 55359 ❑ CableTool ❑ Driven : Dug ❑ Auger �Rotary ❑ Jetted �' Show exact location of well in section grid with"X". . Sketch map of well location. ❑ __,___ ____ _.___ _ ._____ _ Showing property lines, - �� r0ads and buildings. DRILLING FLUID WELL HYDROFFACTURED? C_:YES f]QVO " � bentonite � , i i i � � FROM_,.___ __ft.to ft. p _i _i_ _i_ _i_ ��---- USE C Monitoring �� Heating/Cooling i i i i �Domestic ❑ Communit PWS _i_ _�_ _a_ _i_ � ❑ Irrigation Y ❑ �ndustry/Commercial i i i i .. � � f7 Noncommunity PWS ❑ Remedial yy E �. \ ❑ Environ.Bore Hole ❑ Dewatering � � � � � T � � ,v i i r -r �/Z�Mia � s�� CASING Drive Shoe? ❑ Yes No HOLE DIAM. _� i i i_ I -,,. ❑ Steel ❑ Threaded ❑ Welded � - �- -� - -� ` �Plastic ❑ �1 Mile-� � f'�-`` � CASING DIAMETER WEIGHT (� PROPERTY OWNER'S NAME r�� in.to_200 ft �+�01 Ibs./ft. in.to �x/ P��1 Sarenson C�n�t�Ctl�� __ in.to ft. _ Ibs./fl. �in.to�`R. Property owner's mailing address if different than well location address indicated above. in.to_ fl. ___ Ibs./fl. __in.to__ft. ` 5 2 5 C t y Rd 9 2 SCREEN OPEN HOLE Maple Pilin, IKN 55359 Make��_ f�om_ __f�.�o h. Type_—.4�_g�_t�_S�__g�_�_.__ Diam. �f�1 - i��i s --s— SIOUGauze _�� _ Length __ Set between ft.and ft. FITTI�# � STATIC WATER LEVEL WELL OWNEF'S NAME __��_�___ft. f�eelow ❑ above land surface Date measured�_��_r 'Z r PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. __�_�._ft. afler ��_hrs.pumping ��g.p.m. WELL HEAD COMPLETION a. ♦ �Pitless adapter manufacturer W��`��8 1.e� Model ____, _ . ❑ Casing Protection_ ___ �2 in.above grade ❑ At-grade(Emironmental Wells and Borings ONLY) � GROUTING INFORMATION Well grouted?�Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete �High Solids Bentonite MATERIAL �� from �_to_ ._�_ft. ..�.�_�_ ❑ yds. f`�/bags �� ;� topsoil black soft 0 2 ,��'__ �� _" naturs-t--P�i'��.� eags . o-om to_._ n. NEAREST KNOWN SOURCE OF CONTAMINATION - t�` .,, ` Cla �I,ZON s�edium � 32 - �-c�- feet _ ______C`. direction ��>; type Well disinfected upon completion? I�fes ❑ No � C1A CB SOfL �Z �,�V PUMP ❑ Not installed Date installed ___1i�2_��l�L..___. $�� 8 .�.�l� 1�tl 150 Manufacturer's name _. __.E}��t�v J'S�L]�_ .._ �•�y . Model number ___ ___.. _. __ HP _.s t 1"L�olts__�3� ' cla brown soft I50 190 '� �" Length of drop pipe_ ��y fl. Capacity _ _________g.p.m. w ��'i 7- — - - Type: �_ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet [1 _ -r� sand brown soft 190 208 — ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes C�(IVo � VARIANCE Was a variance granted from the MDH for this well? ❑ Yes o TN# WELL CONTRACTOR CERTIFICATION Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The intormation contained in this report is true to the best of my knowledge. � i ��es��-��'�c-b/R��No 1 i��'�� 7 Z - / / n I'� � _i G'a�F`Ob ut ri d Representa' igns Date C�1t2C�C MOO[e lO�'I7"OZ /'� (� Name ol Driller Date LOCAL COPY +✓ `�� v HE-01205-07(Rev.2/99) IC#140-0020 y