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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName � WELL AND BORING RECORD 5 � ��j 51 ��nr��'�� Minnesota Statutes Chapter 103! Township Name TownshiP No. Range No. Section No. Fracfion WELL DEPTH(completed) Date Work Completed i3ronc, i i / � � t�7 1 ?� � " 8-29-9? ��. ��. ��. HoCu�se Number,Street Name,City,and Zip Code of Welrl iLocation or Fire Number�]L DRILLWG METHOD 7��J �'�Q.��ut �rm L��sn� y� �i��I�lU� �N. J::-JV'4 ❑ CableTool ❑ Driven ❑ Dug ❑ Auger �9 Rotary ❑ Jetted Show exact location of well in section gri with"X". Sketch map of well location. ❑ Showing property lines, — N Oh roads and buildings. DRILLING FLLUID WELL HYDROFRACTURED? ❑YES ❑NO D$nt.t'i f i :. _i i i i_ � � FROM ft.to_ ft. _ _i_ _i_ _i y� USE Y ❑ Monitoring ❑ Heating/Cooling _S 2�Domestic ❑ Communit PWS _i_ _�_ _�_ _i_ Y ❑ Indusiry/Commercial ❑ Irrigation ❑ Noncommunit PWS w � � � � E T � ❑ Test Well v ❑ Remedial i i � i � � ❑ Dewatering ❑ -r -�- -r- -r / i i i i ��zM�ie � / CASING Drive Shoe? ❑ Yes No HOLE DIAM. _i_ _ i _i_ _i_ � _.� �Steel ❑ Threaded ❑ Welded i i- i i + S ��LC t_t.� Plastic ❑ �-1 Mile-� CASI G DIAMETER WEI T PROPERTY OWNER'S NAME � in.to t`� ft. �� Ibs./ft �' /}� 'jfj��, _, Lynry b i3ctl"1� �C�i�Iil� in.to ft. _ Ibs./ft. ��!toY— t ffj� Propeity owner's mailing address if different than well location address indicated above. ��to K� Ibs./ft. in.to ft. SCREEN OPEN HOLE Make �� from ft.to ft. Type S�c�lT1 ��"+v � - -� Diam. SIoUGauze Length . �,`.,_._...�.`��j Set between ft.and ft. FITTINGS: ' '-� STATIC WATER LEVEL a_,2{�`��7 J WELL OWNER'S NAME 2 �99 � � ft. ��f'elow ❑ above land surface Date measured ��Q�• � PUMPING LEVEL(below land surface) Well owner's mailing address if different than properry owner's address�mdicated above. ��L ft. after � hrs.pumping 3�1 i..1I� g.p.m. ` .: .. u'� � WELLHEADCOMPLETION W�i��W�3teT Q�itless adapter manufacturer Model ❑ Casing Protection �F2 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING WFORMATION Well grouted? �1 Yes ❑ No HARDNESS OF Grout Material ❑ Neat cemen ❑ Bentonite Concrete i h Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � 3 �9 ]�� from to . ❑ yds.YJ bags � from to ft. ❑ yds. ❑ bags C�-t_!�7 Brown � �) i from to ft. ❑ yds. ❑ bags 17 o NEARE NOW�J SOURCE OF CONT�AG�'.1 ATIONT^ e j T �-1 u�� s L��1L'�1 Brc��n �� .�V ��l � __ feet G.� � / direction �"C.�type Well disinfected upon completion? Yes ❑ No � y�� �; Gr�vel Cc,l�re� i� f u 6 PUMP �� T�� y-2-97 ❑ Not installed Date installed `�-"�1.Zt�' `,�-';.tltt; $TC3WI3 ? E'� � nnanufacturer'sname Red 3�cket �i 8 .s a ivlodel number HP � Volts :3.ilty 5and Brown `' �� 1 � 105 ' 1 t; Length of drop pipe ft. Capacity g.p.m. wc3ter �c�T1t�w ��e� � . .C'JYJY2 J ��% '�?j �YPe: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes u'roo VARIANCE Was a variance granted from the MDH for this well? ❑ Yes L7 No WELL CONTRACTOR CERTIFICATION Use a second sheet,il 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. DON S�'E��OL�: itiELL I3RILLING C:C;. , Iltic:. Licensee Business Name Lic.or Reg.No. �� '�.� 1 / � �G �"�' � �;--d.5'-7 � �i _;-�`.' ��. Authorized Representative Signature Date � C�1UC'K i�lc,�t:yre 1�-2`�-9/ 5 9 �� 51 Name ol Driller Date L��L vO�� HE-01205-06(Rev.9/96)