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� <br /> WELL CR BORING LOCATION <br /> MINNESOTA DEPARTMENT OF HEALTH MI N AEND BORINI�G NO. ELL <br /> County Name WELL AND BORING RECORD (� �/ <br /> �� i� Minnesota Statutes,Chapter 103/ � �r �✓ � ` 0 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING?EPTH(completed) DATE W�ORK*CLOM��TED <br /> �r000 II8 23 36 i�1E Sl� NE�� G�iS „ C.�LCT <br /> GPS DRILLING METHOD <br /> Lati[ude degrees minutes seconds <br /> LOCATION: _�Cable Tool �]Driven �,Dug <br /> Longitude degrees minutes seconds �_��quger �Rotary �_�,Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number j, �� <br /> 515 Fer�ale 7W � ilLVISVSJ..77� DRILLING FLUID WELL HYDROFRACTURED? �.J Yes j�No <br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring lo-ati . �j'}t�it� From R.To ft. <br /> Showing propert lin , <br /> N roads,buildings,and dir ctio�. USE h]I Domestic ❑Monitoring ❑Heating/Cooling <br /> � � , � �';..-� ��� <br /> �� ,J Noncommunity PWS L i Environ.Bore Hole ❑Industry/Commercial <br /> — -- - - - --- — ! �..__._r. � - <br /> � �Community PWS L I Irrigation !]Remedial <br /> � � <br /> ' - -�-- -'h- ' <br /> �.-,� ,J Elevator L�Dewatering <br /> w ; ; ; ; e "� �Yr � CASING MATERIAL Drive Shoe? �Yes i�No HOLE DIAM. <br /> - '--- --'----�'��-�-`- T �/� 4 -��r, �S eel �Threaded '_�Welded <br /> t <br /> '/Mile , f 'Plastic ❑ <br /> --�-----�-- ---�-- ---�- � <br /> � CASWG <br /> S � �' Diameter Weight Specifications <br /> �1 Mile--{ ���,� �in.to .�� ft. _�_�IbsJft _�in.to��f. <br /> y, 3'/� <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. _ _. _._Ibs./ft. �_,{yin.to_r.�.�p. <br /> �Sl� �ls�d111 �S �T1G♦ in.to n. ib5.in. 37 �to l�i�. <br /> Property owner's mailing address if different than well location address indicated above. p� <br /> SCREEN OPEN HOLE <br /> 1Q��°`����� ����' � Make From Z�v ft. To ��� ft. <br /> �? <br /> t�,T ype_ Diam.__ <br /> �t'�! �^''� ��� Slot/Gauze Length <br /> Set between ft.and it. FITTINGS <br /> STATIC WATER LEVEL <br /> Measured from <br /> llg _ ft Below ;J Aboveland surface �Date measured��� <br /> WELL OWNER'S NAME/COMPANY NAME PUtv���LEVEL(below land surface) � �� <br /> L <br /> ft.after hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> I�Pitless/adapter manufacturer�rhite�ter Model <br /> � �Casing Protection �12 in.above grade <br /> � 1 At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION /� �/� } <br /> Wel��� � �Na tl Jil 'i � <br /> GrouLmater�als�R i Neel qeipent�Bento�p;Concrete ❑Other <br /> �t�.�.LiL 1 1211 7C7 V <br /> From To ft. ❑Yds. �_.�Bags <br /> HARDNESS OF From To fl. n Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO -- <br /> From To ft. ❑Yds. ❑Bags <br /> _ NEAREST KNOWN SOURCE OF CONTAMINATION <br /> 7� ___feet � direction ��tiC type <br /> Well disinfected upon completion? �,�Yes ❑No <br /> PUMP <br /> ��Not installed Date installed L�►""Y-1V <br /> r Manufacturer's name �t..�...0 <br /> Model Number �r��r HP ��� Volts ��� <br /> �' � Length of drop pipe �,y�l ft. Capacity g.p.m. <br /> Type:�`Submersible ��LS.Turbine ❑Reciprocating ��Jet ❑ <br /> `? . . ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? [�Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ��Yes No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,il needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Dc� Stodoia We12 I3r t1.ir�; Ca,. Zrrc. 1�I <br /> Licensee Busines Na e Lic.or Reg.No. <br /> _ �: q..20-10 <br /> if d Represen ative Signa `re Certified Rep.No. Date <br /> LOCALCOPY 7 7 6 g 7 O �k ��� <br /> Name of Driller <br /> IC 140-0020 <br /> HE-01205-12(Rev.12/08) <br />