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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WFLL NO. CountyName WELL AND BORING RECORD 6 4 4 8 6 8 t7e,,,,�,,,� Minnesota Statutes Chapter f03! i�i�ucY Township Name Township No. Ranqe No. Sedion No. Fraction WELL DEPTH(completed) Date Work Completed n. p� 117 23 �3 I�,(�.SE,�. NW ,�. 2l+2 10 02 00 House Number,Street Name,City,and Zip Code of Weil Location or Fire Number DRIIUNG METHOD �75 � � ❑ Cabie Tool ❑ Driven ❑ Dug ❑ Auger �Rotary ❑ Jetted Show exact bcation ot well in sec[ion grid with'X". Sketch map of well location. ❑ Showing property lines, roads and buildings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES �JO N ��V\\\ �C\\\� � i i i W3�T FF20M ft.to (1. -� -�- -�- -i- USE ❑ Monitoring O Heating/Cooling i � � � d L�Domestic ❑ Community PWS O Induslry/Commercial -i- -�- -i- -� b ❑ Irrigation ❑ Noncommunity PWS ❑ Remedial w E� N p v�Q� O Environ.Bore Hole ❑ pewaterin9 O i � � � Q�� -r -�- -r' -r � �e', i � � � ��ZM� CASING Drive Shce? ❑ Yes O No HOLE DIAM. _i_ _ i_ _L_ i I p Sleel ❑ Threaded ❑ Welded � � � � 1 �Piastic ❑ S �-1 1Ala--i CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME _�__in.to��fl. Ibs.ttt. �in.to 2tF2fl. �� tQ in.to R. Ibs./ft. in.to_fl. Property ownefs mailing address if different than well location address indicated above. in.to ft. Ibs.Rt. _in.to_ft. � t�+�J►i VOIkP1�8L1C SCREEN � OPEN HOLE 1� (:,....h. � � Make .TBVCD from tt.to fl. wuaa�.� t�__� �^S_ � � Type ��ori(= Diam. rrdp c iau� SbVGauze �I�Vj ^,. Length S� �,.,.t�,„. Set between [...7/ R.and Lfi2 R. FITTINGS: R-s�:atici STATIC WATER LEVEL WELL OWNER'S NAME 1� ft. �below ❑ above land suAace Date measured 9/�/� Q]��PS CiSI�1tA PUMPING IEVEL(below land surface) Well ownefs mailing address if ditterent than property owner's address indicated above. ft. afler hrs.pumping � W/1�2' g.p.m. WELL HEAD COMPLETION �T� �Pitless adapter manufacturer `'d11� Model �71ft ❑ Casing Protection_ � 12 in.above grade ❑ At-grade(Environmenta�Wells and Borings ONLY) GROUTING INFORMATION Well grouted? L�Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout btaterial ❑ Neat cement ❑ eentonite ❑ Concrete L�High Solids Bento�de MATERIA� irom__.Q_to_�ft. _3�__ O yds. �bags trom to ' R. ❑ yds. ❑ bags � � Q 'L irom to fl. ❑ yds. ❑ bags NEAREST KNOWN SOUFiCE OF CONTAMINATION Y��+�W 2 17 � feet 5'(�t_f�7 direction � rype Well disinfected upon completion7 �Yes ❑ No 17 � PUMP ❑ Not installed Date installed 1�/vL�w .�lul o[ 7V � Manufadurers name �Y7'Y)� . Model number 2�.51514 HP_1�— vm�5 230 W� � � u5 Length ot drop Pipe � R. Capacity � g.p.m. � Type: (�Submersible ❑ L.S.Turbine O Reciprocating ❑ Jet ❑ w � � � ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes l�No � � � � � �� VARIANCE � Was a vanance granted irom the MDH for this well? � Yes d1No TNN WELL CONTRACTOR CERTIFICATION Use.a second sheef,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapier 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The information contained in this report is true to the best ot my knowledge Licensee Business Lic.or Reg.No. / 10/03/00 Authorized Representafive Signature Date Joe Stevens 10/Ol3/00 Name olOriller Date IMPORTANT-FIIE WITH PROPERTY PAPERS � 4 4 8 F 8 WELL OWNER COPY `� HE-01205-07(Rev.2/99)