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. : �r �m� � � _ . �: �� . . � � � T _ . WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M�N AND BORING NO. ELL `�ounty Name WELL AND BORING RECORD 7 7 0 0 2 6 �� i� Minnesota Statutes,Chapter f037 Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED Ut� i�� 0� �w r� s�+� " a"Z�-�s GPS DRILLING METHOD Latitude degrees minutes seconds LOCATION: -- i, - Longitude degrees ___ minutes seconds � Cable Tool I �Driven :�'Dug �Auger �Rotary ❑Jetted House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number �; 1305 Elnn�ood Ave viV�aV ��"'' DRILLING FLUID WELL HYDROFRACTURED? �Yes �;�Vo Show exact location of well/boring in section grid with"X:' ;,,�F Sketch map of well/boring location. From ft.To ft. Showing property lines, N roads,buildings,and direction. USE �pomestic �]Monitoring �i Heating/Cooling __L___1__ __L____i_ ��.� ' I Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ' ' ' ' -�� --�„ � !-.J Community PWS ❑Irrigation ��Remedial I � � I .� .;� � --i--------- ---=-- ---+-- '�„'- i �Elevator `_Dewatering ] W , , , ; E � CASING MATERIAL Drive Shoe? '�I Yes '�,�fGo HOLE DIAM. ------ ----- ---�-----:-- T , , , , Mile I � ee _ hreaded _ elded ;, ;st i � r �w �� lastic � --,-----'----�-----:- 1 ;�. ,� �� ; ; ; ; CASING S a.,y� Diameter Weight Specifications �-1 Mile—� � �T in.to �•� ft ��16s./ft. �� .to��R. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft Ibs./ft. _ in.to ft. � � � y.� in.to ft Ibs./tt. in.ro ft. ��' OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN ._ �� Make__�Tow3.w� w�� From ft. To ft. 5832 Li.ncol.n Dr, �t 12� Type _ Diam. �--- SbUG u3ze�-q�-��— Le ty �y(�$� t�+I 5543fs Setbetween ��1`l_ ft.and_ ft. FI�NGS STATIC WATER L Measured from r� �/� �� _ft.I�Below r�Above land surface Date measured�6�—'V7 WELL OWNER'S NAME/COMPANY NAME , PUMPING LEVEL(below land surface) I�� ft.after �� hrs.pumping � g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION � �Pitless/adapter manufacturer �, '� �_ � -' AAodel Casing Protection ��Y �12 in.above grade [J Abgrade(Environmental Well and Boring ONLY) �� GROUTING INFORMATION Well grouted �es ❑No 'i Grout materials ��–�.Neat cement ;�entonite � ��'Concrete [_�Other From�To�t,d/rt. � �-�Yds. �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From��To�.�t j��$��. �Bags MATERIAL From��To��t. �_ �_,'Yds �}�ags NEAREST KNOWN SOURCE OF CONTAMINATION ell� ��t Q �� feet �� 3� direction � . type Well disinfected upon completion? es L�No $Q�t IS � PUMP , � c '�'Not installed Date installed � � � �� 1� � �� Manufacturer's name � � � �� O t�� Model Number HP�Volts � � 1 Length of drop pipe � � ft. Capacity g.p.m. 1 1� � 1''f� ,� Type:[��Submersible ❑LS.Turbine ❑ReciprOca[ing �.�Jet ❑ 1.7CV�7 L ABANDONED WELLS - Does property have any not in use and not sealed well(s)? I J Yes o VARIANCE ��(, �.i Was a variance granted from the MDH for this well? � es ��'�.No TNq ��-�''��? WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true ro the best of my knowledge. Use a second sheet,il needed �� + REMARKS,ELEVATION,SOURCE OF DATA,etc. R�Fr�,.7. Well, 1?till#.t� Ca�� CK:. a divfsitm of Don Stodola Well Drilling Co., Inc• 169I � . Licensee Business Name . Lic.or Reg.No. ' I '�� / 1 � , i . pre§entati e SiQq2( . Certified Rep.No. Date � 770026 ��` �e LOCAL COPY Name of Driller IC 140-0020 HE-01205-11(Rev.3/07)