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_ � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD f �,� Henne �Q Minnesota Statutes Chapter 1031 "..` ^� ( � J �. Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n OrOnO 117 23 OS ,. - ,. 112 8-29-02 House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD / L C7 Cable Tool ❑ Driven ❑ Dug 3'i 3 5 �+ La A� S t 0��Tl� 5 5 3 5 6 C� Auger �Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch ap of well location. ❑ _ a Sho �ng property lines, - - - ro s and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �fVO N /� i i i i � bQQt�jj�,te' .FROM____ ft.to ft. -i -i- -i- -i- USE ❑ Monitoring ❑ Heating/Cooling i i i � Ff��Domestic -'- -�- -�- -'- ,❑ Irrigation � CommunityPWS ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w e T ❑ Erniron.Bore Hole — — i i i i ❑ Dewatering n i r i r �/zIM1e ��..-��_� � CASING Drive Shoe9 ❑ Yes �No HOLE DIAM. _i i i i_ � ❑ Steel ❑ Threaded ❑ Welded i _i_ _i _ _i ,, O�Plastic ❑ S ' p '`)�� �--1 Mile-� '.J�, CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME __ !�in.to��l{ft. ��Q1 �bs./R �in.t�ft. �as�a �� in.to_ _._ft _._ Ibs./tt. _in.to ft. Property owner's mailing address if different Ihan well location address indicated above. __ in.to R ___Ibs./ft. in.to ft. 196Q0 Silver Lake 1�1 SCREEN OPENHOLE Shorewood, MN 55331 Make Johnson __ ,�om nfo ___n. Type�l�i�.gs��_t�e��—Diam. SIoUGauze� Length (}� ,�_�_ ..__ Set between ft.and fl. FITTINGS: STATIC WATER LEVEL p—qA WELL OWNER'S NAME __��ft.6Ybelow ❑ above land surface Date measured�� r PUMPING LEVEL(below land surface) L Well owner's mailing address if different than property owner's address indicated above. .._.�Q�_ft, after_____��hrs.pumping 9� g.p.m. � WELL HEAD COMPLETION L � r�yI'Pitless adapter manutacturer ��i�t e WA C e C Model .. 'LJ Casing Protection _ __._ ___ �2 in.above grade ��. Cl At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Wellgrouted? f�Yes ❑ No % HARDNESS OF Grout Material �l Neat cement ❑ Bentonite ❑ Concrete Hi h Solids Bentonite k ' GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO /� 9 from y__.to��ft. �� ❑ yds. �bags from _to__ R _____ C7 yds. ❑ bags from . . _to_____ ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATIO� __ )_ feet ��____direction � � i•.�-_ type Well disinfected upon completion? C]/S'es ❑ No �,„ . . � i; PUMP �l Not installed Date installed _Zg� �w�q��2 Manu(acturer's name _��rmo.t_Qr_ _ _- - Model number . _. _.___ HP �_4 Volts 11� Length of drop pipe /� fl. Capacity __ _._____g.p.m. �.i-�-.--. Type: , ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABAN ONED WELLS Does property have any not in use and not sealed well(s)? :� Yes GLNo l� VARIANCE Was a variance granted from the MDH for this well? es �,-1 No TN#��,�_ 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 informstion contained in this report is true to the best of my knowledge. D�t�__�..L�s3�18 WQl IT)rillixtg_r�_T. Inr__ __27 72': Licensee Business N e Lrc.or Reg.No. r' �� 'l 1z-5-o� '��E?!��'"qtii zed ep e Date --- --- � �A A�� Name ol nller ate LOCAL COPY � � 7 8 91 HE-01205-07(Rev.?J99) IC#140-0020