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_ . . .. 1. ^� '� ..��c �.-' i --.„�.��Y.�_,.� ,,,-�}: R , � - :�T WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 6 215 6 7 �ienn��in Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Com leted dre►na 117 23 4 SE SE N�v 1�0 " �%i 3�t�(� ��. ��. ��. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 1775 D2€r Rtit1 Ttd1I E. OtOtic7 55356 � CableTool ❑ Driven ❑ Dug ❑ Auger �(Rotary ❑ Jetted Show exact location of well in section grid with"X". � � Sketch map of well location. ❑ � Showing property lines, roads and buildings. DRILLING FLUID WELL HYDFiOFRACTURED? ❑YES ❑,p(p J N -�- - �- -� - -�- �1� �.G�i /�<..L�n �a L�r FROM ft.to ft. .� i i i i ,�. USE ❑ Monitoring ❑ Heating/Cooling � i i i ` fs �..Domestic ❑ Communi PWS -�- -�- -i- -�- f � ❑ Irrigation Ty ❑ Industry/Commercial i i i i ! ❑ Noncommunity PWS ❑ Remedial y�r E � t ❑ Test Well ❑ Dewatering ❑ � � � � T � i i i -r �/2M1e CASING Drive Shoe? ❑ Yes C�lo HOLE DIAM. _i_ _ i_ _i_ _i_ � 4 ❑ Steel ❑ Threaded ❑ Welded i i i i � 0(Plastic ❑ s �-1 Mne—� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � in.to 1�� ft. �'�� Ibs./ft. � in.to ��1 cT g�� r G111.`Z in.to ft. __ Ibs./ft. _��,to�1�� Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. C�5�1 Orchid Lanr� N SCREEN OPENHOLE 1�+3�1� �SrovB� � ��J�j� Make j��:'�tf1� from ft.to ft. Type c.7 ,. Diam. I`�p —F::�-L��z'Q�Z�-Efir� f SIoUGauze �7(Y Length ],� Setber,�een 13[h.and �.�Q n. FlrrwGs: STATIC WATER LEVEL WELL OWNER'S NAME �� ft. O�elow ❑ above land surface Date measured PUMPING LEVEL(below land surface) !t � Well owner's mailing address if different than property owner's address indicated above. �1 ft. afler J hrs.pumping �v g.p.m. WELL HEAD COMPLETION C�Pitlessadaptermanufacturer '�hite��at�r Model '�'�� ❑ Casing Protection ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �.Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ❑ eenton e � Concrete ❑�'Ii Solids Bentonite GEOLOGICAL MATERIALS CO�OR MATERIAL FROM TO �C from �� to � ft. ❑ yds. LS'bags .� from to ft. ❑ yds. ❑ bags �rCs� 5c�il �J'.la�.`K SO�t'. � from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION 3r�t1Ct�/ CZ3� UL'C�&It1 ��Cl. j 1 �� feet �'�� direction �E''WFc'.C' j�].�� Well disinfected upon completion? O�es ❑ No �adlc: & clay j:,iu� �+�d. 16 �3 PUMP � ❑ Not installed Date installed VP j V�av � san�i � �ra��1 mix m�:c�. 91 i0 Manufacturer's name Sallt�� f�1�a� �Jllj@ gj2Cl• 1�2 11 Modelnumber HP 1 Volts 2�� Length of drop pipe �� tt. Capacity '�� g.p.m. sand �Zx �EC�• 1�5 �� Type: �ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS 5C $y�jl(��T (�,1,a�! rQd ��' j� Does property have any not in use and not sealed well(s)? ❑ Yes O'ICo SOf�. �'L V 1� VARIANCE 5a�u & �r��j �jX �l�d• 1�a .�� Was a variance granted from the MDH for this well? ❑ Yes ❑� WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. i��S i��ll Dril.lin� �72?6 Licensee Business Name Lic.or Reg.No. •�^' ....� /. ''�-r` �'�i-.;-�-�., �/.�'>�� .4uthorized Representative Signature�� Date Rabert E. ��c,ciola, �.o�� _ �1�2/00 Name of Driller HE 01205-06(Rev.9/97) LOCAL COPY i� 2�.5 6 7