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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyNarne Hen31epz.�i WELL AND BORING RECORD � � 72 � � Minnesota Statutes Chapter f03! �}o�n��p��me To�n�ip No. Range No.� SectiopyNp. Fraction WELL DEPTH(completed) � Date Work Co leted 1 ! L Lx4 1��i n. �— tl—�� v, l. va �o�sg�lumhe[�tl,etNaq�„�1Lv,ap�Zip�Code�of WeI1lqGaijoa i � =r Fi��u�tler� DRILLI�Ca le�Tool � Rotary ❑ D n d tJ �I- ict fi '.L E- 11 tJZ t.lIl ❑ Auger a Show exact location of well in s ction grid with" p Sketch map of well location. ❑ ��f'I.. ��A� / I"`, Showing property lines, � ads and buildin s. DRILLIA{GFLUI.�`}��i t� WELL HYDROFRACTURED? ❑YES LJ NO N t�f�jl i i i i FROM ft.to ft. _i _i_ _i_ _i_ USE ❑ Monitoring ❑ Heating/Cooling i i i i s '� Domestic _i_ _�_ _�_ _i_ �Y�"� ❑ Community PWS ❑ Industry/Commercial � i � � ❑ Irrigation ❑ Noncommunit PWS � Y ❑ Remedial w E ❑ Test Well i i � i T ❑ Dewatering ❑ -r -�- -r- -r i � i � yzM�ie CASING Drive Shoe? ❑ Yes No HOLE DIAM. _i i _i_ _i_ ❑ Steel ❑ Threaded ❑ Welded � -,- � � 1 Glue � Plastic ❑ S �-1 Mile-� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � � �� in.to 1 7 1 ft. � "� Ibs./ft � -�� trharles C.uaci Ca. ��.t in.to ft. Ibs./ft. ��7��' Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. SCREEN ,��2� OPEN HOLE iBG� WQoddale Drive �c�} Make from ft.to ft. bd�r?cibury, Mn. �;51 �:� TYPe ._ .a�,n �ss S�eeZ Diam. Slot/Gauze .V�� Length _ Set between ft.and `�ft. FITTINGS: STATIC WATE V�L � WELL OWNER'S NAME � ft. �below ❑ above land surtace Date measured �—j�—'��' PUMqING,1,F�1EL(below land surfac� Well owner's mailing address if different than property owner's address indicated above. _j �� ft. after hrs.pumping �� 1'�g.p.m. �YELL HEAD COMPLETION �J Pitless adapter manufacturer �rl l t�'�1V t�� Model ❑ Casing Protection �J 12 in.above grade ❑ At-grade(Environmental Welis and Borings ONLY) GROUTING INFORMVTION Well grouted? �E] Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cem t� ❑ Benton �p Concrete -C�laHigh So�ids Bentpnite MATERIAL from � to �t' ft. " ❑ yds.rb bags F�ill-C1ay Br'C��:I2 ;� t; ' 3 ' from to n. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags rL'C.`n :?f:al E�,.t,s�(,k �' j i � ! NEAR KNOWNSOURCEOFCOf�,MINATI� i /"' .��✓� U /� feet + ' direction �`�` ��Gtype Well disinfected upon completion? -�Yes ❑ No C.�Ci� �S�t3�llr`I� M U � Jt.; PUMP S��'—h� J ❑ Not installed Date installed 8rat'e�' R'O�"Or Z'1 `' ��` �L C' Manufacturer's name 5'L�"�� 1 Model number �5�'��=��S �� i ` Volts �4 tF CI zy Grc.y :7 1 i�W 1 �:U �:6 i 8 Length of drop pipe ft. Capacity g.p.m. �`1�� , Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ Grey �, 1 �t:� 1�i:� ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes � No VARIANCE Was a variance granted from the MDH tor this well? ❑ Yes �No WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The information contained in this report is true to the best of my knowledge. ._ IiCti� ��'iUD`vLA WEL,L DhIL�It�G CO. , INC. __ ; ;,'z-C r _ �. � Licensee Business Name Lic.or Reg.No. � / j� E,.�;� 2. 6 ��9? �F,, ,�`;' � ,.�' J i E-9 F, " � Authorized Representative Signature Date 9 '� .....� {��L1C1C ��(7C�Z'd'-'.'' ��—�s:—��5 v+1y " �' Name ol Driller HE 01205-06(Rev.9/96) LOCAL CQPY j � �j � �i �j