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� � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName ��,�ne�,�ri WELL AND BORING RECORD 5 ��; �j �j l Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � Date Work Completed fl. ��';'�r�;� I 1 "t �;:.. 1.�� ;_'; o �r' �_c — ��, �, �. - House Number,Street Name,City,and Zip Code o1f Well Location or Fire Number DRILLING METHOD �:��":; DE?f�Y' �Zl,ij'! �j"r41.11 (,I�L��I��r �1 2. `_.�. :rif> ❑ CableTool ❑ Driven ❑ Dug ❑ Auger C�SRotary O Jetted Show exact location of well in section grid wit "X;',�� J yJ Sketch map of well location. ❑ c Showing property lines, �'Toads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO N �� BEJ'li.�.��Il� : .. FAOM n.to h. -�- -�- -�_ -�- x �' USE ❑ Monitoring ❑ Heating/Cooling i i i � C]xDomestic ❑ Communit PWS _i_ _�_ _�_ _i_ ❑ Irrigation y ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial W I i I 1 E� ❑ Test Well ❑ Dewatering ❑ i i i r ,/ZMie CASING Drive Shoe? ❑ Yes o HOLE DIAM. _i i � _�_ � ❑ Steel ❑ Threaded ❑ Welded i - i- -i - i C37'Plastic ❑ s �-1 Mile� CASING DIAMETER WEIGHT i PROPERTY OWNER'S NAME � in.to � � ft. � '� Ibs./ft. �� in.io `6ft. �f,._-'t�-'I_ [-iT'.:�2i��.:"r`, �7.:tiit�3c1T��' in.to n. �bs./n. ��irf:�to�—�'�ft. ' Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. SCREEN -r.1,.........�. OPEN HOLE �:.TI7TS�u\ST�- Make from ft.to ft. Type -��'t�'.' {.�. �'tC..''LZ Diam. ` SIoUGauze • } } �p�" �Length Set between � /7 � ft.and��ft. FITTINGS !.n � 5O� S+.'; � STATIC WATER LEVEL t�' t �t_.'. WELL OWNER'S NAME `_1 ft.2� below ❑ above land surface Date measured _;{i—� PUMPING LEVEL(below la�d surface) Well owner's mailing address if different than property owner's address indicated above. � i.i F ft. after ! . �� hrs.pumping c'.^ c i 1 1"�g.p.m. v�tFLL HEAD COMPLETION �x G�1�2�.�4i'�i'i:E:Z Li Pitless adapter manufacturer 'Model ❑ Casing Protection �12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? C��Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite O Concrete ❑ddigh Solids Bentonite MATERIAL � from to ft. ❑ yds. ❑ bags ��C>�3 5C�]..� �i�'r:C fC `; �. ' � � irom to_ ft. ❑ yds. ❑ bags ~ from to ft. ❑ yds. ❑ bags '� r ^ i �NEAR �0 lSOURCE OF Cpp�,MINATION ti y<'i� bZ'Ob;F'i .� _, �_ `�.,, �. -rcf � feet '---�G�✓/ )� direction'J� �� type Well disinfected upon completion? ❑ Yes ❑ No c�, y Gr��y �: . _ t �: i PUMP .�'ii4(: �z2 : VFT'1. l:(-�Z(:�' -�'tt �i i'- � t �c- o❑ Not installed Date installed ��`��' Manufacturer's name ��'f.! a��aC�CE.`� i.t<1�� G7.��„'ti" �.; };: E j t��!. �odel number HP �� Volts ?'�� Length of drop pipe �� ft. Capacity 1�`� g.p.m. ;�t3,TlC�. � i.],T�r?j r9ZQy .��i �!.'!.! + � �J� tType: �T'6ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ 3 ABANDONED WELLS :'�.�:il(� �C 1 t.�(�1 F.!`1I i �'i � :r i F ��S`' tDoes property have any not in use and not sealed well(s)? ❑ Yes �o VARIANCE Was a variance granted from the MDH for this well? ❑ Yes �TJo 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. �2`-,Ft �.J�i�: :;�."tf'��rL`. L"v3Z"�.il� ��'1�.L1.ZlvV L.ls. � IjVC. � �9�v Licensee Business ame Lic.or Reg.No. �� ~� `�.iL� � -'� ",�� ; . _:-9� . �.,�- fi-�%�i%�'�� Authorized Representative Signature Date ..,} � �%�° C�tti�i"1ri I�Sr7c,Y� '� (.;... i_`i'i Name ol Driller Date LOCAL ��r Y 5 9 6 d � � HE-01205-06(Rev.9/96) ,