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WE�L LOe,ATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. .•^c�ityName WELL AND BORING RECORD 5 g ��j � 7 FT�nnepin Minnesota Statutes Chapte�103/ Tota��p�f�� Township No. Range No. Section No. Fraction WELL DEPTH(completed) ; � Date Work Completed � 7 � L� .�iFi 41r, n �l.—� �--�+:> v. v. v. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 3�r N�z'�h �'�T'Ilrlctic? 12U�d Ci2'�'s t;� Ail��.�v� 1 ❑ CableTool �Driven ❑ 0�9 ❑ Auger Rotary ❑ Jetted Show exact location of well in section grid.with"X". � Sketch map of well location. ❑ _ Showin�property lines, , �� roa� and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O N N�tural _i i i i_ M� 4� FROM tt.to ft. � -�' -�_ _� V USE 1 ❑ Monitoring ❑ Heating/Cooling i i i i e �}'Domestic _i_ _�_ _i_ _i_ �� O ❑ Community PWS ❑ Industry/Commercial i � � i ❑ Irrigation ❑ Noncommunit PWS w E ❑ Test Well Y ❑ Remedial i i i i T ^1 ❑ Dewatering ❑ -r -�- -r- -r � i � � � �/ZM11e � � CASING Driye Shoe? �F Yes ❑ No HOLE DIAM. _i i _i_ _i_ � (�, C't Steel C�Threaded ❑ Welded i -i- i i � ❑ Plastic ❑ S �-1 Mile-� CASING DIAMETER .��J L WEIGk{T} � 5(,., 1 � PROPERTY OWNER'S NAME in.to ft. Ibs./ft. �Szuc� Bren Hc,In�� to Property owner's mailing address it different than well location address indicated above. in.to �ii E) S BrC?ttCiWc�L�J SCREEN . .__ OPEN HQI�,, e �,� '., i , �c:yz�ir� , �112. :.��1�� Make—_� �.__ __ . ..... . � from � ��, n.co � n. - Type �,j��{ Diam. SIoVGauze Length Set between ft.and ft. FITTINGS: STATIC yVATER LEVEL �{ WELL OWNER'S NAME ��t ft. Q'below ❑ above land surface Date measured �� "�� PUMP�P{.G�EVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. � ft. after 'j •c� hrs.pumping ��` �3 r g p m WELL HEAD COMPLETION ❑ Pitless adapter manufacturer Model ❑ Casing Protection ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? -�5 Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ❑ Benroni ❑ Concrete i h Solids Bentonite GEOLOGICAL MATERIALS COLOR FROM TO � . �':F1�9 4 MATERIAL from_ t` to ��ft. = • 5� yds.t3 bags '� " � i � r�'� � from to ft. ❑ yds. ❑ bags C3.G..y/lt�r �r,�l �X�� : � ��-�` .�Z� t from to fl. ❑ yds. ❑ bags Glay Gr�v� ;; ✓�� t ��' i NEARE N60URCEOFCO INATI C ,3" ' feet � t..�� direction �+��.�. type Well disinfected upon completion? �Yes ❑ No ...� Sanc� Grey 5 9�. ` 1 15 PUMP f�Not installed Date installed �lay/cr�u�1 Br�:�•�a�k M 11!� �� ManufacWrer's name . .s'�"r3T1C2St.C7IlE' (jp'e (q)� i;��. �l �t'. � 1 '��- Modelnumber HP Volis �Tr Length of drop pipe ft. Capacity g.p.m. Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS y[ Does property have any not in use and not sealed well(s)? ❑ Yes ❑l�o VARIANCE � Was a variance granted from the MDH for this well? ❑ Yes �No 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. G��?� ��`.f.'G�i;_�Lt1. Yr�.I.,L r7RILI.iIvG �_:t:?. , IATC. L��see Business Name � Lic.or Reg.No. � � "� � - _j,�/�. . . . .. Authorized Representative Signature Date �..'`i?i.1C:ri> �$(�ii1� ,L—� 1--�� � Name of Oriller Oate t� " 5966 � 7 ��°�� L'�'Y HE-0720506(Rev.9/96) � ,