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€F��°��;�� WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o��tYName � �; WELL AND BORING RECORD 615 2�8 ��n��,1 j� Minnesota Statutes Chapter f03I Township Name Township No. Range No. Sectlon �}. -�Fr+�¢tion WELL DEPTH(completed) Date Work Completed U,:o��r� 117 2:s � S iti,, S,�i ��k� i i U n i/�.�./t}i� House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ,� /;):3 U;:`4�'l� �(J[i �l r• �,• U.r1331� i;1:}.a::y� � Cable Tool ❑ Driven ❑ Dug ❑ Auger X! Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ A 1 � Showing property lines, /V roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES [�VO N � � � � - _,_ ..._.._...r....-.. Mf.'�ir.�L FROM n.co n. -; -;- -;- -,- .,,_,___�,.,, ,��.�--� USE ❑ Monitoring ❑ Heating/Cooling i � i i � Domestic ❑ Communit PWS _i_ _a_ _�_ _i_ � ❑ Irrigation Y ❑ Industry/Commercial ��:.�4~�'`�� ❑ Noncommunity PWS ❑ Remedial w � � � � E ` � ❑ Test Well i i i i T ._`„i'"".^.� i, �`�, ❑ Dewaterin9 ❑ i i i r +ZIM,ia �" '""""""`""'� ,�i CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. t,... _�_ _!_ _!_ _�_ I ` �N� ❑ Steel ❑ Threaded ❑ Welded ' ' � ' 1 ` � j�-7 Plastic ❑ s �-1 Mile-� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 1! in.to_��_�ft. L�� Ibs./ft. �in.to `}�ft. in.to ft. Ibs./ft. __��to f_�_�, Property owner's mailing address it different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. ,(,{pj�,�j3` P(Zg t SCREEN OPEN HOLE �iy �Y'ruf�uia 'i'rdl.�. Make tilU� from ft.to ft. i�r O LL�♦ l��l 5 5.�5� TYPe L,() Diam. ��p SIoUGauze �i(1 ��(l Length j(il+ Set between ft.and ft. FITTINGS: STATIC WATER LEVEL , WELL OWNER'S NAME �l} R. fXbelow ❑ above land surface Date measured PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. /�ft. after � hrs.pumping :.�� g.p.m. WELL HEAD COMPLETtON Tal Pitlessadaptermanufacturer idhY�ewat�r Model ��`'� ❑ Casing Protection ❑ 12 in.above grade � ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? O�es ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete q�iigh Solids Bentonite MATERIAL from��to�ft. ❑ yds. �bags from to ft. ❑ yds. ❑ bags � d+ �'2 j 1 i;�i��y 21 :�`.�j,� � '�¢ from to ft. ❑ yds. ❑ bags � NEAREST KNOWN SOURCE OF CONTAMINATION ��;i�i St71j 1j�.t��.k 3C}l:�. �i :3 ��e feet jl�r��] direction ;u�w�Y.' }L;tihld Well disinfected upon completion? �Yes ❑ No C.`.l ct� `a7�:.3 a`Ll }iA�L'i. � i t] PUMP ❑ Not installed Date installed i f�61 Uu c:l�y t�lu� �1��• 1� �� Manufacturersname �t.d—l21L� Modelnumber__ HP� Volts �`�v 5 d t!C.� b� y}r ci V� �1 X ti1�Cl. y� '�1� Length of drop pipe ��Q ft. Capacity 1 ti g.p.m. Type: fXSubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS , Does property have any not in use and not sealed well(s)? ❑ Yes f�+PJo VARIANCE Was a variance granted from the MDH for this well? ❑ Yes C�'�+(Vo WELL CONTRACTOR CERTIFICATION Use a second sheet,if 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. r2E5 in�ll L�t2.11.1T1� � l'117iJ � Licensee Business Name Lic.or Reg.N9 f/ � f r�� ' �. F ij ��/{.�� f F ! Authorized Representative Signature Date �v��rt �:. 5todol�, 3r. llilloU Name of Driller HE 01205-06(Rev.9/97) LOCAL COPY 615 2 4 �