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_ _ __ . , .. , _ _ __ �._� �-,— .�___ � �! MINNESOTA UNIQUE WELL ` V�E'L�OF31NG LOCATION MINNESOTA DEPARTMENT OP HEALTH AND BORING NO. ' ca��Y N�,nP WELL AND BORLNG RECORD 7 g 2 0 2 0 � Minnesota Statutes,Chapter f037 Township Name Township No. Range No. Section No. Fraction WELIJBORING DEPTH(completed) DATE WORK COMPLETED �COI'1�� Z.�S � �! � ■`i+y� �+�a �� n' �16—I3 GPS DRILLING METHOD - Latitude degrees minutes seconds LOCATION: -- - ❑CableTool f]Driven Longitude degrees minutes ___ _ seconds []Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other !)S �G[1t�C � if t)s�a�o► 553�31 DRILLING FLUID WELL HYDROFRACTURED? C Yes o Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. '�t��tC From ft.To ft. Showing property lines, - N roads,buildings,and direction. USE 1/Domestic ❑Monitoring ❑Heating/Cooling y`i �`: __;___ __�__ __;____;__ �� '�]Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial e --'--- —;--- --`-----�-- [�Elevator ❑Dewatering ❑ ��':. �� w ; ; ; ; E CASING MATERIAL Drive Shoe? �Yes ❑No HOLE DIAM. .,; --�-----�--- --F-----%-- -�" T �Steel fxThreaded [�Welded ± ; , ; , Mile j Plastic ___ _ / C�'� � ' --;-----�------%-- --�- I � 1 �Q/� CASWG S � Diameter Weight Specifications �—�nniie� ;�.,n .�,.JLR...�.q„ � � .__�_in.To Z��ft. Ibs./ft. �in.To_�ft . PROPERTY OWNER'S NAME/COMPANY NAME - � - � in.To____ ft. _ Ibs./ft. �__in.To2��fl J� � ��y„� in.To ft. Ibs./ft. �$�.To�_ft ��5� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN Make From�_ ft. To ZDV ft. Type Diam._____ SIoUGauze Lengih Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from �,�{3 ft. Below r 1 Above land surface Date measured_.�._��+ WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ` � ft.after v hrs.pumping � _�.p.m. Well/boring owner's mailing address if ditterent than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacture��te�t� __ Model - �Casing protection ____ �2 in.above grade ❑At-grade ❑Well House [�Hand Pump GROUTING WFORMATION(specify bentonite,cement-sand,neaPcement,concrete,cuttings,or other) Material��rom_�To__�ft. _ �_�_� '�_;Yds. �ags _ Matenal�!_�1�To AM_ft _ ___ []Yds. �]Bags Z 1 --ZTL - HARDNESS OF Matenal From To ft ❑Yds. []Bags �? --------- -- ----�-- .. GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From_ To___ _Bags NEAREST KNOWN SOURCE OF CONTAMINATION �� fliV�3 �Q�t 0 ,7E7 /CG� feet 1-�-� direction��' type � Well disinfected upon completion? j�Yes ❑No L7Li�i7 lOC7C.Li.� .3V SZ PUMP �_;Notinstalled Dateinstalled __,______�1,.�-i,3__._ � C� �y,� �� +�� Manufacturer'sname_.7L12�Cler ______. _ �1u�e� ModelNumber HP ��! Volts 6.7V bOtilt�[ �BCC� �.2 1�.3 ---- Length of drop pipe �� ft. Capacity g.p.m .._�1/ �� i� �t� 11 9 t�1 Type:� . ubmersible ��_I LS.Turbine ❑Reciprocating ❑Jet ❑ �1� L i i.7 1 1 ABANDONED WELLS �u} �� j� �� e�� Does property have any not in use and not sealed well(s)? ❑Yes No �i1i�l 1 '� VARIANCE �� q� Was a variance granted from the MDH for this well? -❑Yes � No TN# � � WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. I � �� ZY� 2g1 The information contained in this report is hue to the best of my knowledge. �lC Use a secon t.if needed � � REMARKS,ELEVATION,SOURCE OF L��t�e/ ��'i�n Stodoia t�ZI �rilling Go�� 1�• 1�91 �� 8�Y -------- -------- —___ --- - ��`� �� `�� Licensee Business Name Lic.or Reg.No. / _ � �_. .-' 7-22-13 r�� d resentative Sign2ture � Certified Rep.No. Date � 792020 �' ��'� LOCAL COPY - --- ---- Name of Driller IC 140-0020 HE-01205-13(flev.11/10)