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1-VELL OR BORING LOCATION. MINNESOTA DEPARTMENT OF HEALTH M/N AND BORIN�G NO. ELL County Name a_ WELL AND BORING RECORD , ��Lepia Minnesota Statutes,Chapter 1037 �� Township Name Townsfiip No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 4rono � 1I? 23 OT �� 120• " +�-30-48 GPS � DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ , Longitude degrees minutes seconds ��Cable Tool �� Driven �Dug — � J Auger [PRotary Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� .� k,_,;.� VVV �DZ��t AiaN �IIA OrOIIOJ- • 35364 DRILLING FLUID T WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. Y From fl.To ft. Showing property lines, roads,buildings,and direction. USE N I j Domestic _ .Monitoring �, J Heating/Cooling ___ __ ��-�--��---.,_ �� ! I 'i Noncommunity PWS �Environ.Bore Hole .._j Industry/Commercial �":-� �� - f Community PWS ❑Irrigation _�Remedial .1 -- .�` �- �f�/ � '�Elevator ❑Dewatering �� ___ `/�/ , , � ` E "`" �" CASING MATERIAL � � HOLE DIAM � ; T I�'�� Drive Shoe. �Yes �No --�-----�-----�-- � - I ...-�"""'a ___ _ . . . .. , ; ; ; �r� . .} �;�S hrea e elded teel i�T d d �W NI� , , , '/Miie �'� � ! �— - -� , , , , � - I lastic �_j --;-----T-----%-----�-- CASING S � Diameter Weight Specifications ~� �1 Mile� �j 1 ,�__ in.to___��ft. ��_�_,Ibs./R �� _ $_ _in.to.�ft. �� _ PROPERTY OWNER'S NAME/COMPANY NAME � in.ro __,___ft. Ibs./k. __ in.to_ ___ft. �{is�►'� �i��6 �it �1"AAE,�a Piltt.AwtiOII in.to___ n. �bs.�tt. _ in.to 2 Z! Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make �Q� From ft. To ft. � TYpe �tas��ir�Diam. '�M � SIoUGauze_.. s��$___.. __. Length__ . $t Set between_ ft.and it FITTINGS STATIC WATER LEVEL Measured from�Q*_L�• 9� it.[�iBelow ' Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(below land surface) � l�i ft.after �a� hrs.pumping �� g.p m. �WelUboring owner's'mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t,�j � L� - �Pitless/adaptermanufacturer wlii�.�Y�Lv�odel `,�Casing Protection �, �2 in.above grade '�' —'At-grade(Environmental Well and Boring ONLY) -�,4� GROUTING INFORMATION Well grouted �Yes ❑No Grout materials ',_j Neat cement [�entonite [Concrete ❑Other From�__To�ft. � ❑Yds. [}�ags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. ']Yds. �Bags MATERIAL From To ft. ❑Yds. I^Bags s` A NEAREST KNOt W�N SOURCE OF CONTAMINATI N _'.t,f 4f .f_., �. � Clag �_�� a�+ V* �+�` feet --�� direction i�i r 7 4'r.: 'J�:.W�e — F . �"� �.� ��—�;-�. �j nr�� SO" �Qn*��q Well disinfected upon completion? j�+res ❑No �� f r f PUMP i ;Not installed Date installed ��0�. Manufacturer's name Model Number HP�_Volts Length of drop pipe �V ft. Capacity g.p.m. Type:��ubmersible ❑LS.Turbine �Reciprocating ❑Jet �.�.j � ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes � �No VARIANCE Was a variance granted irom the MDH for this well? ❑Yes ��lo TN# 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 to the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. � 31'�DOLl1 iiSLL DB�IrLIi�6 6'4. r: I�.`. Licensee Business Name "� Lic.or Reg.No. 1892 - --�5��- S"1"�g - � �61 r n i ign Certified Rep.No. Date LOCAL COt'Y 7 6 0 6 21 Name of Driller IC 140-0020 HE-01205-71(Rev.3/07)